A clinical and echocardiographic score to differentiate pulmonary hypertension due to heart failure with preserved ejection fraction from idiopathic pulmonary hypertension: the PH-HFPEF score

Background

One of the most challenging differential diagnoses in pulmonary hypertension clinical practice, is the discrimination between idiopathic pulmonary arterial hypertension (IPAH) and pulmonary hypertension due to heart failure with preserved ejection fraction (PH-HFpEF).

Aim

We elaborate a score (considering patient clinical history, demographics, and echocardiographic characteristics) that can predict, noninvasively, PH-HFpEF vs IPAH diagnosis.

Methods

Data were prospectively collected on 466 consecutive patients with a final diagnosis of IPAH or PH-HFpEF referred to a single tertiary pulmonary vascular disease centre. Data included clinical history, demographics, and parameters of an electrocardiogram and a transthoracic echocardiogram. A multivariate regression model was developed to predict a PH-HFpEF diagnosis, and an integer risk score was generated using adjusted regression coefficients of the multivariate logistic regression analysis.

Results

At the multivariate logistic regression a high ratio between left and right ventricular dimensions, a history of atrial fibrillation (AF), a high body mass index (BMI), a reduced mitral deceleration time and a high E-wave at trans-mitral doppler, an advanced age and a high right ventricular fractional area change (FAC) were predictors of PH-HFpEF. The derived PH-HFPEF score is shown in Table 1 and, with a cut-point ≥11, it yielded a specificity/sensitivity, respectively, for the diagnosis of PH-HFpEF, of 100%/49% with an AUC of 0.987.

Conclusions

The PH-HFPEF score can predict PH-HFpEF vs IPAH. The PH-HFPEF score may be used to potentially avoid an invasive diagnostic testing in almost half of PH-HFpEF patients.

Funding Acknowledgement

Type of funding sources: None.

The effect of Working Alliance on drug attitude in patients with Major Depressive Disorder

Introduction

Working Alliance is defined as the emotional bond and the agreement on therapeutic goals and tasks between patients and therapists. Despite the wide use of the construct of working alliance in research on psychotherapy, few studies have investigated the role of working alliance in influencing adherence to pharmacotherapy, and drug attitude. A deeper knowledge of the interplay between working alliance and drug attitude could help to challenge low adherence to psychopharmacological treatments in Major Depressive Disorder.

Objectives

This study aimed to investigate the relationship between working alliance and drug attitude in patients with Major Depressive Disorder.

Methods

27 patients admitted in the Psychiatric Unit of Careggi with diagnosis of Major Depressive Disorders were enrolled. Working Alliance Inventory - patient version (WAI-P), Drug Attitude Inventory (DAI) and Beliefs about Medicines (BMQ) were administered. Pearson’s correlation was used to assess relationships between variables.

Results

A significant positive correlation was detected between BMQ total scores, DAI total scores and WAI-P task, bond, and goal subscales. Correlations between WAI-P subscales and BMQ and DAI total scores DAI total scores BMQ total scores r p r p WAI-P task 0.551 0.003 0.613 0.001 WAI-P bond 0.430 0.001 0.560 0.004 WAI-P goal 0.621 0.001 0.603 0.002

Conclusions

Such preliminary data suggest a relationship between Working Alliance and drug attitude. This could contribute to provide tools to challenge low adherence to psychopharmacological treatments in patients with Major Depressive Disorder.

Disclosure

No significant relationships.

Therapeutic drug monitoring of LAI antipsychotics as a predictor of clinical relapse: a one-year follow-up

Introduction

Clinical relapses in schizophrenia remain a frequent event. Long-acting injectable (LAI) antipsychotics enhance adherence, but low blood levels can sometimes be observed despite an adequate posology. Nonetheless, the evaluation of this parameter is uncommon in clinical practice.

Objectives

To explore the potential advantages of therapeutic drug monitoring (TDM) of LAIs as a predictor of relapse in clinically stable outpatients with schizophrenia.

Methods

44 individuals who had reached the pharmacokinetic steady state of LAI treatment (paliperidone, olanzapine, aripiprazole) underwent an anamnestic and psychopathological assessment. LAI blood levels were measured using liquid chromatography-mass spectrometry and classified as “in range” or “under range” according to the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) guideline values. Individuals who relapsed during the one-year follow-up were compared to non-relapsers (Fisher’s exact test, χ2 or Mann-Whitney U). An exploratory binary logistic regression tested the role of other possible relevant predictors of relapse.

Results

No differences were observed in baseline use of mood stabilisers (p=0.211), antidepressants (p=0.530), or prescribed LAI (p=0.563). Other comparisons are presented in the table: among these variables, in-range LAI levels were the only significant predictor of relapse (F=5.95, p=0.015; OR 0.04, 95%CI 0.02-0.56). Relapse (n=6) No relapse (n=38) p Age (years) 41.33±10.78 43.95±12.98 0.667 Male 4 (66.7%) 21 (55.3%) 0.600 Illness duration (years) 21.83±2.64 19.13±11.82 0.289 Previous acute episodes 3.50±1.05 3.29±1.47 0.652 PANSS-total 49.33±14.83 42.74±14.14 0.231 In-range LAI 2 (33.3%) 32 (84.2%) 0.006

Conclusions

TDM of LAIs may optimise the clinical management of schizophrenia by highlighting a suboptimal dosage and a consequent higher relapse risk. Large-scale, drug-specific assessments are needed to confirm these findings.

Disclosure

No significant relationships.

Preoccupied attachment style and beliefs about medicines in patients with Major Depressive Disorder

Introduction

Attachment style is defined by the American Psychological Association as “the characteristic way people relate to others in the context of intimate relationships”. Four attachment styles have been described: secure, fearful, preoccupied, and dismissing. While the effect of attachment style on psychotherapy was widely investigated, few studies have investigated its role in determining beliefs about medicines in patients with Major Depressive Disorder (MDD).

Objectives

This study aimed to investigate the relationship between preoccupied attachment style and beliefs about medicines in patients with MDD.

Methods

27 patients admitted in the Psychiatric Unit of Careggi with diagnosis of MDD were enrolled. Working Alliance Inventory - patient version (WAI-P), Relationship Style Questionnaire (RSQ) and Beliefs about Medicines Questionnaire (BMQ) were administered. An ANCOVA model having BMQ total score as dependent variable and age, sex, RSQ preoccupied attachment subscale and WAI-P task subscale as predictors was considered. WAI-P task was intended to assess the role of agreement on therapeutic choices.

Results

The overall model was significant (F(4,22)=9,571, P<0.001) and explained 66.8% of BMQ total score variance (R²=0.668). Both RSQ preoccupied attachment subscale (B=3.331, t(22)=3.907, p=0.001) and WAI-P task subscale (B=0.238, t(22)=4.565, p<0.001) showed a positive correlation with BMQ total scores. RSQ preoccupied attachment subscale explained 44.6% of variance of BMQ total scores (partial η²=0.446), WAI-P task explained 52.3% of variance of BMQ total scores (partial η²= 0.523). Age (B=0.059, t(22)=1.588, p=0.129) and sex (F(1,22)=0.035, p=0.854) had no significant effect.

Conclusions

These preliminary data suggest a possible influence of preoccupied attachment style on beliefs about medicines in patients with MDD.

Disclosure

No significant relationships.

Echocardiographic predictors of low risk haemodynamic parameters in patients with pulmonary arterial hypertension

Background

A periodic and multiparametric assessment of the risk profile of patients with pulmonary arterial hypertension (PAH) is essential for a low-risk oriented treatment strategy. Haemodynamic parameters anyway cannot be collected at each scheduled outpatients clinic follow-up visit.

Purpose

To evaluate echocardiographic predictors of haemodynamic low-risk parameters in patients with PAH.

Methods

Patients with PAH referred to our centre were included up to 31 December 2019. All patients underwent baseline demographic, clinical, WHO functional class, 6-minute walk test, brain natriuretic peptide (BNP), right cardiac catheterization and echocardiographic evaluation. Through a multivariate logistic regression analysis we evaluate the echocardiographic predictors of low risk for: 1) BNP/right atrial pressure (RAP): NT-proBNP &lt;300 ng/l/BNP &lt;50 ng/l AND RAP &lt;8 mmHg; 2) cardiac index (CI)/mixed venous oxygen saturation (SvO2): CI ≥2.5 l/min/m2 AND SvO2 &gt;65%. Echocardiographic parameters cut-offs were chosen on the basis of the ROC curves or Literature data.

Results

1020 patients were included. The two analysis were performed independently.

1. Independent echocardiographic predictors of low-risk BNP/RAP were: indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume. We elaborated a score utilizing these parameter cut-offs: an indexed right atrial area of 10.4–15 cm2/m2, a mitral E/A ratio of 0.8, dimension and inspiratory collapse of inferior vena cava indicative of 0–5 vs 5–10 vs 10–20 mmHg and an indexed left ventricular diastolic volume of 32 ml/m2. The score has AUC: 0.62, specificity: 92%, sensitivity: 33%, negative predictive value: 70%, positive predictive value: 69%.

2. Independent echocardiographic predictors of low-risk CI/SvO2 were: S wave at TDI, Tei index, tricuspid annular plane systolic excursion (TAPSE), indexed left ventricular diastolic volume and the severity of the tricuspid regurgitation. We elaborated a score utilizing these parameter cut-offs: an S wave at TDI of 9.5 cm/s, a Tei index of 0.4, a TAPSE of 1.7 cm, an indexed left ventricular diastolic volume of 32 ml/m2 and a mild vs more than mild tricuspid regurgitation. The score has AUC: 0.70, specificity: 89%, sensitivity: 50%, negative predictive value: 71%, positive predictive value: 77%.

Conclusion

Echocardiographic parameters can be used to rule out the presence of low-risk BNP/RAP values (indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume) and low-risk CI/SvO2 (S wave at TDI, Tei index, TAPSE, indexed left ventricular diastolic volume and severity of tricuspid regurgitation).

Funding Acknowledgement

Type of funding sources: None.

Survival of patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension listed for lung transplantation

Background

Lung transplantation (LT) still remains a treatment option for patients with pulmonary arterial hypertension (PAH) and not operable chronic thromboembolic pulmonary hypertension patients (CTEPH).

Purpose

The study is intended to compare the survival of transplant recipients (TR) and the survival of not-transplanted (NT) patients since listing.

Methods

We included all patients with PAH and not-operable CTEPH listed for LT. The survival of NT, TR and of all listed patients was evaluated starting from the date of listing (patients were censored as alive at the time of LT). The survival of TR was also evaluated starting from the date of the LT.

Results

125 patients were included (112, 90% had PAH). Fifty-eight (46%) patients were transplanted, after a mean waiting time of 1.5±1.3 years. Forty-one patients (33%) died while on the list and 25 (20%) patients were alive on the list on December 2019. The survival of NT patients at 1, 3 and 5 years after listing was 74%, 42%, 33%, respectively. The survival of TR patients at 1, 3 and 5 years after listing was 90%, 70%, 63%, respectively. The survival of all patients since listing (intention to treat analysis) at 1, 3 and 5 years was 85%, 59%, 48% respectively. The survival of TR at 1, 3 and 5 years since transplantation was 63%, 61%, 59%, respectively.

Conclusions

Despite biases in the comparison of non-randomized groups, the data confirm a better long-term survival since listing of TR as compared with NT PAH or not-operable CTEPH patients.

Funding Acknowledgement

Type of funding sources: None.

Role of cardiac magnetic resonance in stratifying the prognosis of patients with pulmonary arterial hypertension

Background

Pulmonary arterial hypertension (PAH) is a rare disease characterized by a complex remodeling of heart structures. Cardiac magnetic resonance (CMR) is the gold standard for a non-invasive evaluation of right ventricle (RV) volumes and mass.

Purpose

To define the relationship between clinical, functional, biochemical, haemodynamic and CMR parameters and survival in patients with PAH.

Methods

Consecutive patients with PAH referred to our centre underwent clinical, functional, brain natriuretic peptide (BNP) plasma levels, haemodynamic and CMR evaluation. All patients were treated according to current guidelines. Univariate Cox analysis for survival was performed. Parameters with a p-value &lt;0.1 at the univariate analysis were included in the multivariate analysis.

Results

One hundred forty-seven patients with PAH (mean age 49±17 years, 69% female) were included in the study. Etiology of PAH was: idiopathic/heritable (49%), associated with connective tissue disease (19%), congenital heart disease (12%), portal hypertension/HIV infection (12%) and pulmonary veno-occlusive disease (8%). Thirty-six patients died during follow-up. Parameters significantly associated with mortality at the univariate analysis were age [Hazard Ratio (95% Confidence Interval): 1.043 (1.020–1.067); p&lt;0.001], six-minute walk test (6MWT) [HR: 0.995 (0.993–0.998); p&lt;0.001], WHO-functional class [HR: 2.489 (1.025–6.041); p=0.044], idiopathic-heritable-congenital heart disease aetiology [HR: 0.182 (0.085–0.389); p&lt;0.001], connective tissue disease aetiology [HR: 2.274 (1.099–4.704); p=0.027], pulmonary veno-occlusive disease aetiology [HR: 5.864 (2.328–14.773); p&lt;0.001], right atrial pressure [HR: 1.098 (1.032–1.169); p=0.003], pulmonary artery oxygen saturation [HR: 0.947 (0.921–0.975); p&lt;0.001], BNP levels [HR: 2.214 (1.213–4.039); p=0.010], RV wall thickness [HR: 0.633 (0.399–1.006); p=0.053], RV end diastolic volume [HR: 1.012 (1.003–1.021); p=0.007], RV end systolic volume [HR: 1.014 (1.003–1.024); p=0.011]. Parameters independently associated with mortality at the multivariate analysis were age [HR: 1.035 (1.006–1.064); p=0.018], idiopathic-heritable-congenital heart disease aetiology [HR: 0.355 (0.146–0.860); p=0.022], pulmonary veno-occlusive disease aetiology [HR: 3.129 (1.071–9.143); p=0.037], pulmonary artery oxygen saturation [HR: 0.953 (0.919–0.989); p=0.011], RV wall thickness [HR: 0.527 (0.300–0.927); p=0.026], RV end systolic volume [HR: 1.016 (1.003–1.029); p=0.014].

Conclusion

RV wall thickness and RV end-systolic volume are associated with prognosis in patients with PAH independently from clinical and haemodynamic characteristics. These parameters may be used in the overall risk stratification of PAH patients.

Funding Acknowledgement

Type of funding sources: None.

Drug attitude inventory is relevant to LAI treatment persistence in schizophrenia: Preliminary results

Introduction

Patients’ attitudes and subjective experience are crucial in the management of severe mental illness, but their practical value is overlooked.

Objectives

To identify predictors of future adherence to LAI antipsychotic maintenance treatment of schizophrenia among socio-demographic, clinical, and psychometric characteristics – including Drug Attitude Inventory-10 (DAI-10) and Subjective Well-being under Neuroleptics short form (SWN-K) scores.

Methods

Retrospective baseline data from 53 clinically stable outpatients with schizophrenia switched from oral to LAI therapy were collected. Patients continuing treatment at the time of analysis (n=29) were compared to those who had discontinued it (n=24). Selected variables were further evaluated in survival analyses.

Results

Between-group differences are presented in Table 1 (**: p<0.01; *: p<0.05).Continued treatmentDiscontinued treatmentχ2 or tTreatment persistence (months)63.79±21.0123.88±25.806.21**Age (years)39.17±10.1135.58±13.391.11Male15 (51.7%)13 (54.1%)0.03Single20 (69.0%)15 (62.5%)0.25Instruction (years)13.28±3.3111.83±3.561.53Employed20 (69.0%)7 (29.2%)8.32**Illness duration (years)17.69±10.5313.42±11.361.42Previous hospitalisations2.10±1.322.67±1.86-1.29MADRS13.59±9.0614.67±8.99-0.43YMRS5.52±5.576.00±9.94-0.22p-PANSS12.17±5.2014.38±6.13-1.41n-PANSS10.90±5.3915.63±7.93-2.48*g-PANSS29.38±10.3333.63±10.26-1.49PANSS52.66±17.5763.96±20.61-2.15*DAI-103.86±4.96-1.13±5.803.38**SWN-K74.93±23.0781.00±15.60-1.09

Cox regression analysis included instruction, employment, hospitalisations, PANSS subscales and DAI-10 scores: a protective role against treatment discontinuation was outlined only for employment (HR 0.16; 95%CI 0.05-0.50) and higher DAI-10 scores (HR 0.85; 95%CI 0.78-0.94). DAI-10 scores delineated distinct adherence trajectories (Figure 1).

Conclusions

Baseline DAI-10 scores may identify patients at risk of dropout after switching to LAI.

Disclosure

No significant relationships.

Prognostic role of comorbidities in patients with pulmonary arterial hypertension

Background

Epidemiology of pulmonary arterial hypertension (PAH) is changing and the age at diagnosis and the prevalence of comorbidities are increasing but their prognostic relevance is substantially undefined.

Purpose

To evaluate the prognostic value of comorbidities in patients with PAH and in the different clinical subgroups.

Methods

All patients with PAH referred to a single centre underwent baseline right heart catheterization, brain natriuretic peptide (BNP) plasma levels, 6-min walking distance (6MWD), WHO functional class and anamnestic comorbidities evaluation. Cox regression model was used for analysis (p-value &lt;0.1 was considered for inclusion in multivariate analysis).

Results

1311 patients were included [age 51 years; aetiology: 522 idiopathic/heritable/drug-induced (I/H/D)-PAH, 258 connective tissue disease (CTD)-associated PAH, 242 congenital heart disease (CHD)-associated PAH, 196 portal hypertension/HIV (PoHIV)-associated PAH and 93 pulmonary veno-occlusive disease (PVOD)]. 5% of patients have no comorbidities. At multivariate analysis comorbidities independently associated with prognosis are: systemic hypertension in I/H/D [HR 0.616, p=0.030], mean systemic blood pressure in CTD [HR 0.980, p=0.002] and PVOD [HR 0.962, p=0.006], dyslipidemia in CTD [HR 0.447, p=0.001] and PoHIV [HR 0.201, p=0.026], estimated glomerular filtration rate in PoHIV [HR 1.000, p&lt;0.001] and body mass index (BMI) [HR 0.966, p=0.069] in CTD. In CHD comorbidities are not independent determinants of prognosis. Other variables independently predictive of a worse prognosis are: advanced age in all PAH subgroups except PVOD; male gender in I/H/D; reduced 6MWD in I/H/D, CTD and PVOD; high BNP in I/H/D, CHD and PVOD; low cardiac index in CTD, high right atrial pressure in I/H/D and low mixed venous oxygen saturation in CHD.

Conclusion

The age at PAH diagnosis and the prevalence of comorbidities are increasing but their prognostic role seems of poor relevance as we found a protective role of these variables: high systemic blood pressure (maybe indicative of a better haemodynamic stability) in I/H/D, CTD and PVOD; dyslipidemia and high BMI (maybe indicative of a better nutritional status and a less severe autoimmune disease) in CTD; dyslipidemia and a high glomerular filtration rate (both indicative of a less severe liver disease) in PoHIV.

Funding Acknowledgement

Type of funding source: None

Short term effect of Selexipag in comparison to parenteral prostacyclin analogues in pulmonary arterial hypertension patients started on double-combination therapy with ERA and PDE-5 inhibitors

Background

The event-driven, phase 3, randomized, double-blind, placebo-controlled GRIPHON trial demonstrated that Selexipag reduces the risk of a composite end point of death or morbidity events in patients with pulmonary arterial hypertension (PAH). Despite the advantage of a per os formulation, its efficacy in comparison to parenteral prostacyclin analogues in patients already on oral double-combination therapy with endothelin receptor antagonist (ERA) and phosphodiesterase-5 inhibitor (PDE5-I) is not known.

Purpose

The aim of this study was to compare the effects of Selexipag (S) vs subcutaneous Treprostinil (T) vs intravenous Epoprostenol (E) in PAH patients initially started with double-combination therapy with ERA and PDE5-I.

Methods

We enrolled patients on double combination therapy with ERA + PDE5-I starting S, T or E. Drugs were gradually uptitrated to the maximum tolerated/approved dose. All patients were systematically assessed with WHO-functional class (FC), six minute walk test (6MWT) and right heart catheterization before treatment and 3 months after reaching a stable dose of the drug. Baseline characteristics and changes in 6MWT and haemodynamic parameters were analyzed using Wilcoxon signed-rank test and compared between the 3 drugs with Kruskal-Wallis test.

Results

One hundred and seventy-one patients with PAH were enrolled. Results are shown in the Table. Patients with a complete re-evaluation were 61% of S, 85% of T, 79% with E.

Conclusions

S was prescribed to the oldest and least severe PAH patients. E was prescribed to the youngest and most severe PAH patients and led to the strongest improvement of exercise capacity and haemodynamic profile. T has intermediate characteristics.

Table 1

Funding Acknowledgement

Type of funding source: None

Additional role of echocardiogram in pulmonary arterial hypertension risk stratification according to current ESC/ERS guidelines

Background

Current pulmonary hypertension (PH) guidelines stratify the risk of patients with pulmonary arterial hypertension (PAH) using a multiparametric approach. A simplified risk table has been recently proposed and validated without including echocardiographic parameters.

Purpose

We evaluate the additional role of echocardiogram in PAH risk stratification using the recently proposed simplified risk table in patients with idiopathic/heritable (I/H) PAH and PAH associated with connective tissue disease (CTD) and congenital heart disease (CHD).

Methods

All patients with I/H-PAH, CTD-PAH and CHD-PAH referred to a single centre were included from 2003 to 2017. All patients were treated according to PH guidelines. The simplified risk assessment considered the following criteria: WHO functional class, 6-min walking distance, right atrial (RA) pressure or brain natriuretic peptide (BNP) plasma levels and cardiac index (CI) or mixed venous oxygen saturation (SvO2). For the last 2 criteria the worst parameter was chosen. Risk strata were defined as: Low risk= at least 3 low risk and no high-risk criteria; High risk= at least 2 high risk criteria including CI or SvO2; Intermediate risk= definitions of low or high risk not fulfilled. Then we performed a Cox analysis to evaluate the independent echocardiographic predictors of survival that were subsequently added to the simplified risk table to test their additional role in ameliorating risk stratification.

Results

461 treatment-naïve patients were enrolled. Echocardiographic independent predictors of prognosis were the severity of tricuspid regurgitation [HR (95% CI) = 1.013 (1.006–1.021); p-value = 0.001], right atrial area [HR (95% CI) = 1.028 (1.012–1.045); p-value = 0.001] and the presence of pericardial effusion [HR (95% CI) = 1.533 (1.142–2.057); p-value= 0.004]. Only RA area significantly ameliorate the risk stratification power of the recently validated simplified PAH risk table (likelihood ratio chi2 increased from 63.8 to 68.1, likelihood ratio test = 0.039). Due to the significant correlation between RA area and both RA pressure (r=0.470; p&lt;0.001) and BNP (r=0.372; p=0.004), we elaborate a second risk table in which RA area (utilizing the cut-offs proposed by the current PH guidelines) was considered together within the criteria including RA pressure and BNP (the worst parameter of the 3 was considered). Considering the second risk table including RA area the risk stratification power significantly improved (likelihood ratio chi2 increased from 63.8 to 72.7, AIC/BIC decreased from 1956/1964 to 1947/1955).

Conclusions

Echocardiographic RA area significantly improve the risk discrimination power of the recently proposed simplified risk table for patients with PAH.

Funding Acknowledgement

Type of funding source: None

A prospective, observational study of the safety and effectiveness of intramuscular psychotropic treatment in acutely agitated patients with schizophrenia and bipolar mania

This naturalistic, observational pan-European study assessed the safety and early effectiveness of intramuscular (IM) psychotropic treatments in patients with acute agitation suffering from schizophrenia or bipolar mania. One thousand nine hundred and forty of 1945 patients completed the 24-hour observation period after initial IM treatment. Patients from 12 European countries were included (mean age 39 years; 58% male, 66% schizophrenia). IM treatment was at the physician's discretion. The primary objective was to describe the acute tolerability of IM psychotropic therapies in clinical practice, with particular emphasis on EPS. At baseline, 68% of the patients received IM monotherapy, with IM olanzapine most commonly prescribed (36%). During the first 24hours, 190 (9.8%) patients experienced EPS. The occurrence of EPS was statistically significantly lower in patients treated with IM olanzapine compared to those treated with other IM psychotropic medications (mainly typical antipsychotics and benzodiazepines): acute dystonia: 1.1%, 95% CI 0.5–2.3 and 2.9%, CI 2.0–4.0; akathisia: 2.3%, CI 1.3–3.7 and 5.5%, CI 4.3–6.9; Parkinsonism: 2.9%, CI 1.8–4.4 and 7.8%, CI 6.4–9.4, respectively. Anticholinergic treatment was given to 12% IM olanzapine versus 31% non-olanzapine treated patients. Acute agitation after 24hours was reduced by 1.68 (95% CI 1.46–1.91) points on the Clinical Global Impression of Severity (CGI-S) in IM olanzapine patients and 1.51 (95% CI 1.30–1.73) points in non-olanzapine patients. Additional psychotropic medication was required for 90% of the patients during the first 24hours of treatment. Results provide naturalistic evidence for low EPS rates and improvement of agitation with IM psychotropic medications during acute states of patients suffering from acute mania or schizophrenia.

Real-world effectiveness of long acting aripiprazole: Treatment persistence and its correlates in the Italian clinical practice

OBJECTIVES

To identify the variables that are associated with persistence to Aripiprazole-Long Acting (A-LAI), in adult patients with schizophrenia.

METHODS

Observational, retrospective, non-interventional study involving 261 patients with schizophrenia.

RESULTS

Eighty-six percent of study subjects were persistent for at least 6 months. All subjects with baseline CGI-S of 1 or 2, 95% of subjects with CGI-S of 3, 86% with CGI-S of 4, 82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7 were persistent. A-LAI treatment continuation rate was higher in patients with: 1) baseline CGI score ≤ 4; 2) schizophrenia dimension (LDPS) mania score ≤ 5; 3) psychotic spectrum schizoid score ≤ 11.

CONCLUSIONS

A relatively high number of patients (n = 225, 86%) were persistent to A-LAI for at least 6 months. Not surprisingly, very severe patients were more unlikely to be persistent. However, it is noteworthy that a large number of subjects with high CGI score at the time when A-LAI was started (82% of subjects with CGI-S of 5, 73% of subjects with CGI of 6 and 90% of subjects with CGI of 7) were persistent. Larger, controlled, prospective and longer studies are warranted.

Is There an Association Between Body Uneasiness and Aberrant Salience in Anorexic Patients? A Preliminary Study

The process whereby objects and representations come to be attention grabbing and capture thought and behaviour is called salience, and it is defined as aberrant when a significance is allocated to neutral stimuli. The Aberrant Salience Inventory (ASI) is a scale to measure aberrant salience, characterized by 29 dichotomic items. By now, a correlation between aberrant salience and eating disorders is unknown. Aim of this study is to evaluate an alteration of salience in patients with anorexia nervosa, to estimate the existance of a correlation between aberrant salience and the experience of body shape.

Methods

Twenty-six female patients with AN (diagnosed using DSM-5) were enrolled at the Psychiatry Department of Florence. Psychopathological features were assessed at the time of enrollment using the following scales: SCL-90-R, BUT, EDE-Q. Salience alteration was assessed by the means of the ASI. Statistical analysis were realized using SPSS 20.0 with Spearman bivariate correlation.

Results

Mean age was (mean ± SD) 26.2 ± 8.72 and mean Body Mass Index (BMI) 16.1 ± 2.46. Global Severity Index (GSI), Positive Symptom Total (PST) and Positive Symptom Distress Symptom Index (PSDI) were estimated for BUT and SCL-90-R and compared to total value of ASI. Thus, we found a statistical significant (P < 0.05) direct correlation between ASI and BUTpsdi and ASI and SCL-90-Rgsi (correlation coefficient of 0.446 and 0.398, respectively).

Conclusion

In this study, we found a significant direct correlation between Aberrant Salience Inventory (ASI) values and one dimension of body uneasiness in anorexic patients. These preliminary data need further studies with a wider sample to confirm the above-mentioned data.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Economic Aspects in the Treatment of Schizophrenia in Italy: Cost Consequences of an Early Long-acting Injectable Anti-Psychotics (lais) Approach

Purpose

The aim of this analysis was to evaluate the economic consequences of a new treatment approach in the treatment of schizophrenia in the Italian setting. In terms of direct costs, in Italy was estimated that the main driver were represented by hospitalization and residential cost (71% of total direct cost per patient), followed by semi-residential services (13%), anti-psychotic and other drugs (8%) and ambulatory services (8).

Methods

A probabilistic cost consequence model was developed to estimate the potential cost reductions derived from an early treatment with atypical long-acting injectable anti-psychotics (aLAIs) drugs. A systematic literature review was carried out to identify direct and indirect costs associated to the management of schizophrenic patients in Italy. The model projects a scenario analysis in order to estimate potential cost reductions applying a new model management (MoMa) based on patient recovery and early aLAIs treatment.

Results

Overall, the total economic burden associated with schizophrenia was estimated at €2.7 billion per year. A total of 50.5% of the economic burden was related to indirect costs and 49.5% to direct costs. Drug costs correspond to 10% of the total expenditure in terms of direct costs, while hospitalization and residential costs accounts for 81%. Scenario analysis demonstrate a potential cost reduction between 200 million and 300 million based on the effects of MoMa over the reduction of hospitalization and residential costs.

Conclusions

This analysis was the first attempt to translate clinical management aspects in economic consequences and will be a useful instruments for decision maker.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Long acting antipsychotics treatment of schizophrenia: A 24-month prospective study on patient's attitude towards treatment

Introduction

Long-acting injectable (LAI) second-generation antipsychotics (SGAs) are considered an alternative to oral antipsychotics for schizophrenic patients with low adherence to therapy. However, it is still a matter of debate whether LAI-SGAs are able to significantly improve patient's attitudes towards treatment (ATT) [1].

Objective

To investigate the impact of LAI on ATT over 24 months.

Methods

Nineteen schizophrenic patients were switched from either oral olanzapine (11) or paliperidone (8) to the corresponding LAI. Patients were assessed at baseline (T0), after 6 (T1), 12 (T2) and 24 months (T3). Drug Attitude Inventory-10 (DAI-10) [2] was used to assess ATT. Young Mania Rating Scale (YMRS), Montgomery-Asberg Depression Rating Scale (MADRS), Positive and Negative Syndrome Scale (PANSS), and Short Form Health Survey (SF-36) were used for psychopathology evaluations.

Results

Eleven patients reached T3. Eight patients were excluded (4 olanzapine, 4 paliperidone): 4 required a significant change in concomitant treatment, 4 a change of antipsychotic (metabolic comorbidity). No changes in psychopathology occurred between T2 and T3, some scales improved from baseline to T2. DAI-10 mean scores were improved after 12 months, thus not significantly, and were further improved at 24 months (P = .008 vs baseline).

Conclusions

ATT keeps improving after one year of LAI treatment, unrelated to clinical response.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Sustained zero-order delivery of GC-1 from a nanochannel membrane device alleviates metabolic syndrome

BACKGROUND/OBJECTIVES

Our objective was to assess the sustained, low-dose and constant administration of the thyroid receptor-β (TRβ)-selective agonist GC-1 (sobetirome) from a novel nanochannel membrane device (NMD) for drug delivery. As it known to speed up metabolism, accomplish weight loss, improve cholesterol levels and possess anti-diabetic effects, GC-1 was steadily administered by our NMD, consisting of an implantable nanochannel membrane, as an alternative to conventional daily administration, which is subject to compliance issues in clinical settings.

SUBJECTS/METHODS

Diet-induced obese C57BL/J6 male mice were fed a very high-fat diet (VHFD) and received NMD implants subcutaneously. Ten mice per group received capsules containing GC-1 or phosphate-buffered saline (control). Weight, lean and fat mass, as well as cholesterol, triglycerides, insulin and glucose, were monitored for 24 days. After treatment, plasma levels of thyroid-stimulating hormone (TSH) and thyroxine were compared. mRNA levels of a panel of thermogenic markers were examined using real-time PCR in white adipose tissue (WAT) and brown adipose tissue (BAT). Adipose tissue, liver and local inflammatory response to the implant were examined histologically. Pancreatic islet number and β-cell area were assessed.

RESULTS

GC-1 released from the NMD reversed VHFD-induced obesity and normalized serum cholesterol and glycemia. Significant reductions in body weight and fat mass were observed within 10 days, whereas reductions in serum cholesterol and glucose levels were seen within 7 days. The significant decrease in TSH was consistent with TRβ selectivity for GC-1. Levels of transcript for Ucp1 and thermogenic genes PGC1a, Cidea, Dio2 and Cox5a showed significant upregulation in WAT in NMD-GC-1-treated mice, but decreased in BAT. Although mice treated by NMD-GC-1 showed a similar number of pancreatic islets, they exhibited significant increase in β-cell area.

CONCLUSIONS

Our data demonstrate that the NMD implant achieves steady administration of GC-1, offering an effective and tightly controlled molecular delivery system for treatment of obesity and metabolic disease, thereby addressing compliance.

LAI versus oral: A case-control study on subjective experience of antipsychotic maintenance treatment

BACKGROUND

To present real-world evidence on the differences between long-acting injectable (LAI) and oral antipsychotic maintenance treatment (AMT) in terms of subjective well-being, attitudes towards drug and quality of life in a sample of remitted schizophrenic subjects.

METHODS

Twenty outpatients with remitted schizophrenia treated with either olanzapine or paliperidone and switching from the oral to the LAI formulation of their maintenance treatment were recruited before the switch (LAI-AMT group). A group of 20 remitted schizophrenic subjects with oral AMT and matching main sociodemographic, clinical and treatment variables made up the control group (oral-AMT group). All participants were assessed in terms of objective (PANSS, YMRS, MADRS) and subjective (SWN-K, DAI-10, SF-36) treatment outcomes at baseline (T0) and after 6 months (T1).

RESULTS

Between T0 and T1, general psychopathology of the PANSS, DAI-10, and all but one of the SWN-K dimensions (except for social integration), showed significantly higher percentages of improvement in the LAI-AMT group compared to the oral-AMT group. A generalized expansion of health-related quality of life, with better functioning in almost all areas of daily living, was reported by the LAI-AMT group after the 6-month period. In contrast, the oral-AMT group reported a significant worsening of health-related quality of life in the areas of emotional role and social functioning in the same period.

CONCLUSIONS

Our study indicates possible advantages of LAI over oral antipsychotic formulation in terms of subjective experience of maintenance treatment in remitted schizophrenic patients. Size and duration of this study need to be expanded in order to produce more solid and generalizable results.

New interferon-free therapies on HCV+ chronic hepatitis: Overcoming psychiatric side effects in a real world setting

Introduction

Interferon-alpha (IFNα) was the backbone therapy for HCV+ related chronic hepatitis (CH-C). However, it was associated with significant neuropsychiatric side effects and impaired health-related quality of life. Second Generation IFNα-free direct-acting antiviral agents (DAAs) seem to be associated with fewer side effects, better tolerability, high efficacy rates and better patient reported outcomes (PROs) [Younoussi, 2014].

Aims

To describe the neuropsychiatric symptoms and PROs during Second Generation DAAs plus ribavirin oral treatment in a group of CH-C real world patients.

Methods

Nineteen CH-C outpatients, scheduled for IFNα-free treatment, were assessed at enrolment (T0), at 4 (T1) and at 12 (T2) weeks, the end of treatment, by means of MDRS, HAM-D, HAM-A, MRS, Y-BOCS and SF-36. A pharmacological therapy, based on clinical evidence, was provided at psychiatric symptoms onset.

Results

During the treatment, we didn’t report any worsening in the administred psychometric scales. Furthermore, we observed a general improvement at week 12 (T2), statistically significant only for MRS (P < 0.05). Any statistically significant difference was found for SF-36 mean scores comparing T0, T1 and T2. However, SF-36 cluster analysis showed between T0 and T2 a meaningful and significant rise of global health clusters “General health perceptions” (P < 0.05), “Change in overall health status” (P < 0.001) and a significant impairment in cluster “Emotional role functioning” (P < 0.05).

Conclusions

Our real world data are consistent with trial setting results [Younoussi, 2014]. Contrary to previous IFNα-based therapy, new regimens don’t seem to be associated with psychiatric side effects and suggest an immediate gain in general health PROs over the treatment period.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

LAI versus oral antipsychotic maintenance treatment of schizophrenia: A case-control study on subjective experience of treatment

Introduction

Limited research has been devoted to the subjective impact of switching antipsychotic maintenance treatment (AMT) from oral to LAI formulation in schizophrenia.

Objective

To compare LAI AMT with oral AMT in terms of subjective experience of treatment, taking into account the effects on psychopathology.

Methods

Twenty outpatients (7 males, mean age 40.55 ± 11.00 years) with remitted schizophrenia treated with either olanzapine or paliperidone and switching from oral to LAI AMT were recruited before the switch (LAI-AMT group). A group of 20 remitted schizophrenic subjects with oral AMT and matched for the main socio-demographic, clinical and treatment variables made up the controls (oral-AMT group). All participants were assessed by means of the PANSS and of the SWN-K at baseline (T0) and after 6 months (T1).

Results

Between T0 and T1, general psychopathology of the PANSS and all but one of the SWN-K dimensions (except for “social integration”), showed significantly higher percent improvements in the LAI-AMT group compared to the oral-AMT group. After 6 months (T1), the LAI-AMT group showed significantly lower PANSS total and general psychopathology scores, as well as higher mean score of perceived “mental functioning” compared to the oral-AMT group. Item analysis of the general PANSS at T1 showed significant differences between the two groups in anxiety, tension, depression, guilt feelings, poor attention, and active social avoidance.

Conclusions

Our data on switching from oral to LAI AMT in remitted schizophrenia suggest a better efficacy of the latter in terms of improvement of general psychopathology and subjective experience of treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Identification and quantification method of spiramycin and tylosin in feedingstuffs with HPLC-UV/DAD at 1 ppm level

The use of the two macrolides antibiotics Spiramycin (S) and Tylosin (T) as growth promoters in animal feeding has been recently withdrawn in the European Union due to a concern about the outbreaks of farmacoresistance fenomena as a possible hazard for humans. For feed additives monitoring purposes, an analytical method has been developed for their extraction, purification and identification in different animal feedingstuffs (pelleted beef, pig, poultry feeds and calves milk replacer) at a minimum performance required limit (MRPL) of 1 microg g(-1) (ppm). Such limit has been established according to the lowest dosage of additives still able to elicit an appreciable growth promoting effect. Blank feeds were spiked at two concentration levels, 1.0 and 2.5 ppm in six replicates. After methanolic extraction, samples were cleaned up on SPE CN columns and extracts analysed in HPLC-UV/DAD, using a gradient elution. Detection limits, calculated as the tree time mean noise of 20 blank feeds, were 176 and 118 ng g(-1) for S and T, respectively. Results show good repeatability (CV% not exceeding the value of 15) and mean recovery in the range of 99-74% and 81-53% for S and T, respectively, at 1 ppm. When the standards were injected up to 250 ng the chromatographic method can resolve the components of analytes (Spiramycin I, II and III; Tylosin A and B) but can not resolve the components on real feed samples at the spiked levels considered. For this reason the identification and quantification of analytes on matrix were carried out considering the main compound of the drugs (Spiramycin I and Tylosin A). As a verification, the overlapping of UV spectra in the range 220-350 nm between analytical standards and the compounds in the matrix were considered.

Traceability of inbred and crossbred Cinta Senese pigs by evaluating the oxidative stress

Previous studies on the oxidative stress in swine indicated a strong link between the values of reactive oxygen metabolites (ROMs), the subsequent antioxidant adaptive response (OXY) and the genetic selection. Such findings, mainly related to a cardiovascular inadequacy in lean, large muscle blocks and fast growing breeds, is associated with specific metabolic diseases such as porcine stress syndrome and mulberry heart disease. In this study, we investigated the oxidative stress parameters to trace the genetics of Cinta Senese (CS) pigs, a historical breed free-range reared in Siena countryside. Sera from CS (n = 24) and Large White x CS (LW x CS) (n = 24) groups around 120 kg body weight fed the same diet were sampled at slaughter. Sera from wild boars (WB) (n = 24) hunted in the same district were also considered. ROMs and OXY were evaluated in the three groups of swine. Significant differences by one-way anova (P < 0.05) between groups were found for both procedures. ROM levels were lower in WB (9.79 +/- 5.76 mm H2O2) and CS (18.02 +/- 7.42 mm H2O2), and highest in LW x CS (42.78 +/- 8.61 mm H2O2). OXY values ranged from 271.37 +/- 50.90 microm neutralized HOCl (WB) to 343.21 +/- 57.45 microm neutralized HOCl (LW x CS). Results indicated that the evaluation of the oxidative stress can effectively trace the CS pigs, thus aiding in preserving the overall specific traits of such a historical animal.

Dysphoria: a key for 'understanding' delusion?

The 'nonunderstandability' that traditional psychopathology attributes to 'true' delusion does not have a clear demarcation line, but, rather, it is a continuum of various delusional experiences. The attention paid to emotional situations and, specifically, to dysphoria, often contributes to making the delusional phenomenon, and, above all, its persistence, more understandable. A positive correlation between productive psychotic symptoms and the dysphoric mood often prevails in delusions with unfavorable prognoses.

[Palliative cholangiojejunostomy on the duct of hepatic segment III. Our experience]

BACKGROUND

Aim of the paper is to prove that indications for cholangiojejunostomy, in cases when a mean and long term palliation may be expected, are better than those offered by the use of prostheses, without the well known and early bile duct complications.

METHODS

Between 1984 and 1995, 12 patients with obstructive jaundice due to malignancy at the hepatic hilum were treated by segment III Roux-en-y or omega cholangiojejunostomy. In 1 patient with no communication between right and left lobe of the liver, biliary-enteric bypass to segment VI duct was also undertaken; in another with neoplastic stenosis of pylorus gastrojejunostomy was performed. Seven patients had carcinoma of the gallbladder, three hilar cholangiocarcinoma, one gastric carcinoma and one recurrent pancreatic carcinoma.

RESULTS

There were two postoperative deaths, one for myocardial infarction and one for biliary peritonitis. Six patients had complications: four biliary fistulas with spontaneous resolution and two wound infections. Seven of the ten surviving patients experienced complete resolution of jaundice for at least 4 months. The mean survival of surviving patients was 9.7 months. Nine patients developed recurrent jaundice.

CONCLUSIONS

Segment III cholangiojejunostomy is a good palliative treatment in most patients with malignant hilar obstruction.

[Castleman's disease with abdominal localization. Report of an unusual case]

Castleman's disease is an unusual condition characterized by uncontrolled growth of lymphoid tissue. The first case was recorded by Castleman in 1956. In this paper a case of the above-mentioned disease is reported with regard to its unusual clinica-histologic aspect (localized form of plasmacellular type) and surgical therapeutic strategies.

[Hemobilia secondary to percutaneous hepatic biopsy. Report of a clinical case]

The increasingly frequent use of invasive diagnostic and therapeutic procedures concerning the hepatobiliary system has led to a rise in the incidence of hemobilia as well as altering its etiological status. The authors report a clinical case of hemobilia secondary to percutaneous hepatic biopsy which was brought to their attention. This is followed by a short discussion of the etiopatogenesis and diagnostic and therapeutic strategies with special reference to the ratio between the advantages/limits of the methods now available.

[Cholecystolithotomy with cholecystojejunostomy as surgical solution for cholelithiasis in portal hypertension caused by hepatic cirrhosis]

Cholecystolithotomy and cholecystojejunostomy has been carried out on 11 patients with severe hypertension from cirrhosis. The indications were frequently recurring attacks of biliary cholic or acute cholecystitis at onset. There was 1 postoperative death from cardiac infarction and only minor in-hospital morbidity. None of the remaining patients has to date developed post-cholecystojejunostomy sequelae. Except the case of extensive inflammation on gangrena, this procedure appears to be a safe and definitive operation, alternative to subtotal cholecystectomy.

Some remarks on dysphoria from an anthropological point of view

The concept of 'dysphoria', as defined by the Vienna Group from the psychopathological point of view, is analyzed on the anthropological level. In an anthropological perspective, personality is conceived as a factor modulating affective disorders, and the manifold clinical expressions of affective disorders are viewed as functions of the relationship between the entity of the 'endothymic' fluctuations and the amalgam of the person who is in charge to confront and cope with the thymic experience. The hypothesis that dysphoria may be interpreted as a sthenic, oppositional and therefore irritated and hostile personological reaction to the occurrence of endogenous 'restrictive' or 'expansive' mood swings is discussed.

[Contact thermography in breast pathology. A critical review]

The paper reports the Authors' experience in over 12,000 patients affected by manifest or presumed breast pathologies examined using contact thermography and assess the number of correct responses. This technique proved reliable in patients aged under 30 with benign pathologies or palpable nodules. On the other hand, it was not reliable in the case of pathologies with negative objectivity, and therefore in the context of screening programmes for the early diagnosis of tumours.

[Modulation of the expression of histocompatibility antigens class I (HLA-A,B,C) in the human pancreas]

In this study the expression of HLA class I molecules was analysed on caudal portions of ten pancreata from cadaver donors by means of indirect immunoperoxidase and immunophosphatase techniques. In 7 out of ten pancreata the results showed that islets tissue was almost negative for the expression of HLA Class I antigens as opposed to exocrine tissue that appeared positive. Within exocrine tissue and large sized islets strongly positive interstitial cells were also detected. Double stainings showed that the strongly positive interstitial cells expressed also Leu M1 antigens. Preliminary studies on the remaining three pancreata demonstrate an increase of hematic interstitial cells together with a parallel increase of HLA class I antigens by endocrine parenchyma. The above data suggest that an increase of interstitial cells within pancreas may influence islets antigenicity.

Phenomenological questions about obsession and delusion

The problem of the relationship between obsession and delusion is dealt with from descriptive, anthropoanalytical and purely phenomenological points of view. The main differential aspects are focused. The phenomenological concept of the progressive fading of the 'feeling of Ego activity' is proposed as the functional bias at the basis of the continuum linking obsessive symbolic awareness to delusional perception.

Plasma levels and clinical response during treatment with clomipramine

The plasma levels of clomipramine (CI) and its major metabolite desmethylclomipramine (DMCI) may be related to clinical response during treatment of depression. Not all workers have been able to demonstrate such a relationship. The many factors which may affect clinical response include sample selection, assessment and its quantification and kinetic factors. A further investigation into the relationship between plasma levels and response was, therefore, carried out taking these into account and attempting to control them. Sixty-two patients with depressive illness were included. The plasma levels of CI + DMCI as measured on the 28th day of treatment were correlated against clinical response at the time. Patients with the highest combined plasma levels showed the best response. Patients with intermediate plasma levels showed more modest response, whilst lowest plasma levels tended to be shown by patients who exhibited an inadequate response or who relapsed during subsequent outpatient follow-up. The threshold value for satisfactory antidepressant effect appeared to be a combined CI + DMCI plasma level of 160-200 mg/ml.

Double-blind trial with oral versus intravenous clomipramine in primary depression

Intravenous clomipramine and oral clomipramine at a daily dose of 2 mg/kg body weight were compared in a double-blind study of 40 inpatients with primary depressive illness. No significant differences between the two routes of clomipramine administration were found, either in response or in side effects. Steady state was not attained at the 4th week of treatment in 30% of patients. However, combined plasma levels of clomipramine (CI) plus desmethylclomipramine (DMCI) were similar in the two groups at all stages of treatment. The only significant pharmacokinetic difference that was found was in the ratio of DMCI to CI, which was higher among the patients who received the drug orally, but this did not correlate with clinical response. Conversely, Day 28 plasma concentrations of CI, DMCI, and the sum CI + DMCI were significantly related to clinical outcome in the patients treated orally. Among the patients who received the drug intravenously only CI was significantly associated with the percentage reduction of symptoms. By pooling the two groups, CI, DMCI, and their sum all bore relationships to clinical response significant at the 0.01 level.

[Prospects for general psychopathology in modern psychiatry]

The Author describes the interest and the meaning of General Psychopathology in today's Psychiatry. The Author defines the methodological aspects necessary in psychopathology as well as their gnoseological and formative value. The "-structural constants" defined in psychopathology appear irreplaceable in the basic aspects of psychotic mind models, and other dimensions of contemporary psychiatry cannot disregard them. The Author emphasise the risk of an inaccurate and irresponsibly exhaustive use of psychopathological categories in psychiatric practice. However it seems that a conscious exercise of psychopathological methods can avoid confusion about investigatory psychiatric research, and may help recognizing basic structures of psychotic experience. These structures are not only necessary in a diagnostic field, but also for a correct pharmacotherapeutical epproach.