Standard Units for Cannabis Dose: Why is it Important to Standardise Cannabis Dose for Drug Policy and How Can we Enhance its Place on the Public Health Agenda?

Regular cannabis use is associated with several adverse health outcomes including psychosis and cannabis use disorders. In the last decade, prevalence of last-month cannabis use increased by 27% and rate of treatment demand rose from 27 to 35.1 per 100000 inhabitants in Europe. Cannabis legal status is changing worldwide, and recently two European countries (Malta and Luxembourg) legalized its production, sales and use. Even United Nations withdrew cannabis from Schedule IV of the Single Convention on Narcotic Drugs (retained in Schedule I). This new scenario aligns cannabis more closely with alcohol, prescribed drugs or tobacco than illegal drugs. Implementing prevention and harm reduction strategies will be even more relevant in the nearly future. Based on the history with alcohol or tobacco, frequency of use alone misestimates the risks due to limited capture of variations of quantity per day of use on regular users. Standardisation of cannabis use has been proposed in the literature as an instrument to assessing the level of risk. In the Lisbon Addictions Conference (2019) a group of 32 professionals from 13 countries and 10 disciplines participated in a back-casting foresight exercise aiming to addresses challenges of implementation of SJU. They proposed three key steps in the implementation of SJU: 1) constitution of task-force for an evidence-based approach to SJU; 2) expanding the available data on cannabis-related risks; 3) examining the relationship between ‘risky use’ and SJU.

Sodium Oxybate: a Substitute for Alcohol?

Gamma-hydroxybutyrate (GHB) is a neurotransmitter found naturally in the human brain. Sodium oxybate (SO) is the sodium salt of GHB. In 2000 GHB was classified a Schedule I controlled substance, while SO became a Schedule III controlled substance for medicinal use under the Controlled Substances Act. SO and alcohol share a similar pharmacological profile. GHB acts on GABAB receptors and extrasynaptic GABAA receptors resulting in alcohol-mimetic effects in several CNS actions. It substitutes the discriminative stimulus effects of alcohol in rats, and has cross tolerance with alcohol. All together, this leads to think of SO as a substitution therapy for alcohol use disorders. SO was initially studied in the prevention of alcohol withdrawal, and it showed similar efficacy to benzodiacepines. The studies on relapse prevention were developed later and the results are mixed and more complex to understand. While open label studies show a positive effect, RCTs have not been able to show a significant effect for the whole sample. Nevertheless, post-hoc analysis show a robust effect in the subsample of patients with high risk drinking levels, that would be the preferred target for a substitution treatment. The potential for abuse of GHB is well documented, which should be no surprise for a substitution treatment. Nevertheless, when correctly prescribed the risk of abuse of SO remains very low, as shown both in clinical trials and in the pharmacovigilance database, with more than 260000 cases documented. SO can be considered a substitution treatment, effective in patients with high risk drinking levels.

Disclosure

I was investigator in the SMO study on sodium oxybate, funded by D&A Pharma.

The cerebellum and psychological trauma: A systematic review of neuroimaging studies

Psychological trauma is highly prevalent among psychiatric disorders, however, the relationship between trauma, neurobiology and psychopathology is not yet fully understood. The cerebellum has been recognized as a crucial structure for cognition and emotion, however, it has been relatively ignored in the literature of psychological trauma, as it is not considered as part of the traditional fear neuro-circuitry. The aim of this review is to investigate how psychological trauma affects the cerebellum and to make conclusive remarks on whether the cerebellum forms part of the trauma-affected brain circuitry. A total of 267 unique records were screened and 39 studies were included in the review. Structural cerebellar alterations and aberrant cerebellar activity and connectivity in trauma-exposed individuals were consistently reported across studies. Early-onset of adverse experiences was associated with cerebellar alterations in trauma-exposed individuals. Several studies reported alterations in connectivity between the cerebellum and nodes of large-brain networks, which are implicated in several psychiatric disorders, including the default mode network, the salience network and the central executive network. Also, trauma-exposed individuals showed altered resting state and task based cerebellar connectivity with cortical and subcortical structures that are involved in emotion and fear regulation. Our preferred interpretation of the results is through the lens of the Universal Cerebellar Transform, the hypothesis that the cerebellum, given its homogeneous cytoarchitecture, performs a common computation for motor, cognitive and emotional functions. Therefore, trauma-induced alterations in this computation might set the ground for a variety of psychiatric symptoms.

Impact of COVID-19 lockdown on individuals under treatment for substance use disorders: Risk factors for adverse mental health outcomes

BACKGROUND

Individuals with Substance Use Disorders (SUD), are vulnerable to the psychological consequences of the COVID-19 pandemic. This is the first study to assess risk factors of adverse mental health outcomes during lockdown in a SUD population.

METHODS

This was a cross-sectional study, conducted through an online survey that was completed by 303 individuals with SUD, attended in the Addiction Unit of University of Barcelona Clínic Hospital. Sociodemographic and clinical data were collected and descriptive analyses were carried out. Depending on whether individuals reported a worsening or no change/improvement in anxiety and depression symptoms during lockdown, the sample was divided in two groups. A logistic regression was then carried out to identify risk factors associated with adverse mental health outcomes.

RESULTS

Overall, frequency of use for the majority of individuals with SUD remained stable during lockdown in comparison to the pre-lockdown era, although a reduction was found in frequency of tobacco, alcohol, cannabis and cocaine use in a small fraction of individuals with SUD. Symptoms of clinical anxiety were found in 58.7% of the sample while 48.2% of participants scored above the clinical threshold for depression. In addition, 50.3% of the sample reported a deterioration in depression and anxiety symptoms during lockdown that was associated with the following risk factors: previous trauma-exposure, female gender, distress and isolation, income reduction and alcohol use.

CONCLUSION

A high percentage of patients with SUD experienced adverse mental health outcomes during lockdown that were associated with several risk factors, which should be taken into account in policy making and prevention strategies, as well as in clinical practice, in order to provide personalized care to SUD patients during the time of the pandemic.

Cannabis use the week before admission to psychiatric in-patient service as a marker of severity

OBJECTIVE

To evaluate if cannabis dose recorded as standard joint unit (SJU) consumed before admission and other related factors have an influence on psychiatric inpatient's symptom severity and clinical outcomes.

METHODS

Cross-sectional study in an acute psychiatric inpatient unit including 106 individuals. Quantity of cannabis was measured as SJU and symptoms severity through the Brief Psychiatric Rating Scale (BPRS). Secondary outcomes (e.g. length of stay) were also assessed. Bivariate analyses and multivariate analyses were performed to determine the effect of SJU consumed before admission on measures of clinical severity.

RESULTS

Point prevalence of cannabis use before admission was 25.5%. Mean BPRS score was 55.8 (SD = 16.1); and 62.9 (SD = 11.1) among cannabis users. A low degree positive correlation between SJU consumed the week before admission and BPRS score (r_s = 0.28, p = 0.03) was found. In the multivariate analyses both main diagnostic group, Schizophrenia and other psychotic disorders vs. others (Bipolar and Unipolar Affective Disorders and Addictive disorders) (B = 8.327; 95% CI 4.976-11.677) and need of PRN ("pre re nata" or when necessary) administration of antipsychotics and benzodiazepines (B = 12.13; 95% CI 6.868-17.393) were significant predictors, both increasing BPRS score.

CONCLUSIONS

The study did not find a correlation between SJU consumed last week and psychiatric severity. On the other hand, individuals with psychotic disorders reported a higher prevalence of cannabis use the week before admission and displayed higher BPRS scores, which points to the need for the development of tailored interventions for high-risk groups. The SJU is a useful quantification tool suitable for further clinical research.

Tobacco control strategies in psychiatric services in catalonia (Spain)

Introduction

Mortality and morbidity due to smoking in people with mental illnesses are higher than in the general population. However, smoking continues to be allowed in psychiatric premises of many countries despite being prohibited in workplaces including health care services.

Objective

To describe tobacco control strategies undertaken in psychiatric inpatient services and day centers in Catalonia.

Aims

To study tobacco control strategies in psychiatric services in order to identify unmet needs.

Methods

A cross-sectional study including all psychiatric services offering public service in Catalonia (n = 192). The managers answered an on-line questionnaire with 24 items grouped in four dimensions: staff's training & commitment, clinical intervention, management of smoking areas, and communication of smoke-free policies.

Results

186 of the managers (96.9%) responded to the questionnaire. Results showed low levels of implementation of tobacco control strategies, especially in the training and intervention dimensions. 41.0% of the services usually intervened in their patients’ tobacco use but an overall 65.9% didn’t have pharmacotherapy for smoking cessation available. 47.3% of the managers stated that their staff had not enough knowledge on smoking cessation interventions. 38.9% of the services had smoking indoor areas. Day Centers showed the lowest implementation of tobacco control measures while services belonging to the Network of Smoke-free Hospitals showed the highest implementation.

Conclusions

Current Spanish partial law has failed to promote a desirable tobacco control in psychiatric services. There is a need to extend tobacco control policies, specifically in terms of smoking intervention and training, together with a higher availability of resources.

The blind men and the elephant: Systematic review of systematic reviews of cannabis use related health harms

Cannabis is the third most used psychoactive substance worldwide. The legal status of cannabis is changing in many Western countries, while we have very limited knowledge of the public health impact of cannabis-related harms. There is a need for a summary of the evidence of harms and risks attributed to cannabis use, in order to inform the definition of cannabis risky use. We have conducted a systematic review of systematic reviews, aiming to define cannabis-related harms. We included systematic reviews published until July 2018 from six different databases and following the PRISMA guidelines. To assess study quality we applied the AMSTAR 2 tool. A total of 44 systematic reviews, including 1,053 different studies, were eligible for inclusion. Harm was categorized in three dimensions: mental health, somatic harm and physical injury (including mortality). Evidence shows a clear association between cannabis use and psychosis, affective disorders, anxiety, sleep disorders, cognitive failures, respiratory adverse events, cancer, cardiovascular outcomes, and gastrointestinal disorders. Moreover, cannabis use is a risk factor for motor vehicle collision, suicidal behavior and partner and child violence. Cannabis use is a risk factor for several medical conditions and negative social consequences. There is still little data on the dose-dependency of these effects; evidence that is essential in order to define, from a public health perspective, what can be considered risky use of cannabis. This definition should be based on quantitative and qualitative criteria that informs and permits the evaluation of current approaches to a regulated cannabis market.

Improving screening and brief intervention activities in primary health care: Secondary analysis of professional accuracy based on the AUDIT-C

INTRODUCTION AND OBJECTIVE

The ODHIN trial found that training and support and financial reimbursement increased the proportion of patients that were screened and given advice for their heavy drinking in primary health care. However, the impact of these strategies on professional accuracy in delivering screening and brief advice is underresearched and is the focus of this paper.

METHOD

From 120 primary health care units (24 in each jurisdiction: Catalonia, England, the Netherlands, Poland, and Sweden), 746 providers participated in the baseline and the 12-week implementation periods. Accuracy was measured in 2 ways: correctness in completing and scoring the screening instrument, AUDIT-C; the proportion of screen-negative patients given advice, and the proportion of screen-positive patients not given advice. Odds ratios of accuracy were calculated for type of profession and for intervention group: training and support, financial reimbursement, and internet-based counselling.

RESULTS

Thirty-two of 36 711 questionnaires were incorrectly completed, and 65 of 29 641 screen-negative patients were falsely classified. At baseline, 27% of screen-negative patients were given advice, and 22.5% screen-positive patients were not given advice. These proportions halved during the 12-week implementation period, unaffected by training. Financial reimbursement reduced the proportion of screen-positive patients not given advice (OR = 0.56; 95% CI, 0.31-0.99; P < .05).

CONCLUSION

Although the use of AUDIT-C as a screening tool was accurate, a considerable proportion of risky drinkers did not receive advice, which was reduced with financial incentives.

Who receives treatment for alcohol use disorders in the European Union? A cross-sectional representative study in primary and specialized health care

BACKGROUND

Alcohol use disorders (AUDs) are highly prevalent in Europe, but only a minority of those affected receive treatment. It is therefore important to identify factors that predict treatment in order to reframe strategies aimed at improving treatment rates.

METHODS

Representative cross-sectional study with patients aged 18-64 from primary health care (PC, six European countries, n=8476, data collection 01/13-01/14) and from specialized health care (SC, eight European countries, n=1762, data collection 01/13-03/14). For descriptive purposes, six groups were distinguished, based on type of DSM-IV AUD and treatment setting. Treatment status (yes/no) for any treatment (model 1), and for SC treatment (model 2) were main outcome measures in logistic regression models.

RESULTS

AUDs were prevalent in PC (12-month prevalence: 11.8%, 95% confidence interval (CI): 11.2-12.5%), with 17.6% receiving current treatment (95%CI: 15.3-19.9%). There were clear differences between the six groups regarding key variables from all five predictor domains. Prediction of any treatment (model 1) or SC treatment (model 2) was successful with high overall accuracy (both models: 95%), sufficient sensitivity (model 1: 79%/model 2: 76%) and high specificity (both models: 98%). The most predictive single variables were daily drinking level, anxiety, severity of mental distress, and number of inpatient nights during the last 6 months.

CONCLUSIONS

Variables from four domains were highly predictive in identifying treatment for AUD, with SC treatment groups showing very high levels of social disintegration, drinking, comorbidity and functional losses. Earlier intervention and formal treatment for AUD in PC should be implemented to reduce these high levels of adverse outcomes.

Alcohol Dependence, Co-occurring Conditions and Attributable Burden

AIMS

Alcohol dependence is associated with high rates of co-occurring disorders which impact health-related quality of life (HRQoL) and add to the cost-of-illness. This study investigated the burden of alcohol dependence and associated co-occurring conditions on health and productivity.

METHODS

A cross-sectional survey was conducted in eight European countries. Physicians (Psychiatrists and General Practitioners) completed patient record forms, which included assessment of co-occurring conditions, and patients completed matching self-completion forms. Drinking risk level (DRL) was calculated and the relationship between DRL, co-occurring conditions, work productivity, hospitalisations and rehabilitation stays was explored.

RESULTS

Data were collected for 2979 alcohol-dependent patients (mean age 48.8 ± 13.6 years; 70% male). In total, 77% of patients suffered from moderate-to-severe co-occurring psychiatric and/or somatic conditions. High DRL was significantly associated with depression, greater work productivity losses, increased hospitalisations and rehabilitation stays. Co-occurring conditions were significantly associated with poorer HRQoL and decreased work productivity, with a statistical trend towards an increased frequency of rehabilitation stays.

CONCLUSIONS

Alcohol-dependent patients manifest high rates of co-occurring psychiatric and somatic conditions, which are associated with impaired work productivity and HRQoL. The continued burden of illness observed in these already-diagnosed patients suggests an unmet need in both primary and secondary care.

Educational climate perception by preclinical and clinical medical students in five Spanish medical schools

OBJECTIVE

The purpose of this study was to investigate student's perceptions of Educational Climate (EC) in Spanish medical schools, comparing various aspects of EC between the 2nd (preclinical) and the 4th (clinical) years to detect strengths and weaknesses in the on-going curricular reform.

METHODS

This study utilized a cross-sectional design and employed the Spanish version of the "Dundee Ready Education Environment Measure" (DREEM). The survey involved 894 2nd year students and 619 4th year students from five Spanish medical schools.

RESULTS

The global average score of 2nd year students from the five medical schools was found to be significantly higher (116.2±24.9, 58.2% of maximum score) than that observed in 4th year students (104.8±29.5, 52.4% of maximum score). When the results in each medical school were analysed separately, the scores obtained in the 2nd year were almost always significantly higher than in the 4th year for all medical schools, in both the global scales and the different subscales.

CONCLUSIONS

The perception of the EC by 2nd and 4th year students from five Spanish medical schools is more positive than negative although it is significantly lower in the 4th year. In both years, although more evident in the 4th year, students point out the existence of several important "problematic educational areas" associated with the persistence of traditional curricula and teaching methodologies. Our findings of this study should lead medical schools to make a serious reflection and drive the implementation of the necessary changes required to improve teaching, especially during the clinical period.

Assessment of cannabis use disorders: a systematic review of screening and diagnostic instruments

BACKGROUND

Cannabis use and misuse have become a public health problem. There is a need for reliable screening and assessment tools to identify harmful cannabis use at an early stage. We conducted a systematic review of published instruments used to screen and assess cannabis use disorders.

METHOD

We included papers published until January 2013 from seven different databases, following the PRISMA guidelines and a predetermined set of criteria for article selection. Only tools including a quantification of cannabis use and/or a measurement of the severity of dependence were considered.

RESULTS

We identified 34 studies, of which 25 included instruments that met our inclusion criteria: 10 scales to assess cannabis use disorders, seven structured interviews, and eight tools to quantify cannabis use. Both cannabis and substance use scales showed good reliability and were validated in specific populations. Structured interviews were also reliable and showed good validity parameters. Common limitations were inadequate time-frames for screening, lack of brevity, undemonstrated validity for some populations (e.g., psychiatric patients, female gender, adolescents), and lack of relevant information that would enable routine use (e.g., risky use, regular users). Instruments to quantify consumption did not measure grams of the psychoactive compounds, which hampered comparability among different countries or regions where tetrahydrocannabinol concentrations may differ.

CONCLUSIONS

Current instruments available for assessing cannabis use disorders need to be further improved. A standard cannabis unit should be studied and existing instruments should be adapted to this standard unit in order to improve cannabis use assessment.

Nalmefene and its use in alcohol dependence

Nalmefene is the first available drug approved in the E.U. to reduce alcohol use in alcohol-dependent patients. Reduction in alcohol use in heavy drinkers diminishes mortality risk and socio-economic burden. Nalmefene has shown efficacy at 6 months in alcohol-dependent patients with high or very high drinking risk levels in reducing total alcohol consumption (-7.6 g/day [95% confidence interval (CI): -11.6 to -3.5]; P = 0.0003), heavy drinking days (-2.00 days/month [95% CI: -3.00 to -1.00]; P ⟨ 0.00001) and other secondary outcome measures such as γ-glutamyl transferase, alanine aminotransferase, drinking risk level and Clinical Global Impression. It is generally well tolerated and has limited contraindications and interactions. As-needed dosage is a novel concept in the addictions field, which may overcome limitations of traditional regimens. In the pivotal trials, nalmefene was taken 52% of the days and compliance with the as-needed treatment regimen was good (above 80% of the days) in 68% of the nalmefene-treated patients. A new pharmacological approach combined with a brief psychosocial intervention for alcoholism is available and appears to be feasible, safe and efficacious.

Treatment of bullous pemphigoid with low-dose oral cyclophosphamide: a case series of 20 patients

BACKGROUND

Cyclophosphamide has been commonly used for the treatment of pemphigus vulgaris and mucous membrane pemphigoid with satisfactory results. Published data of this therapeutic approach for bullous pemphigoid are scant and showed significant morbidity and mortality.

OBJECTIVE

To assess the clinical efficacy and safety of low-dose oral cyclophosphamide (CFM) (50-100 mg/day) in patients with refractory bullous pemphigoid.

METHODS

We conducted a retrospective study including patients with bullous pemphigoid treated with CFM in the department of Dermatology in the Hospital Clínic of Barcelona, Spain.

RESULTS

Complete response was observed in 11 (58%) over 19 evaluable patients. Cyclophosphamide at 50 mg/day was enough to achieve clinical remission in eight of these patients. Partial response was observed in four (21%) more patients. Bone marrow suppression appeared in 12 (60%) patients, but treatment discontinuation was only required in three (15%) cases. Gastrointestinal intolerance occurred in one (5%) patient. One patient died during therapy from heart failure (not attributed to CFM) and another patient developed acute myeloid leukaemia 1.5 years after CFM therapy.

CONCLUSIONS

In our series, CFM had a marked therapeutic effect in bullous pemphigoid. These results of efficacy are similar to those described in other autoimmune blistering skin diseases. Only a few patients had to discontinue their treatment due to adverse effects. Therefore, we consider that low-dose oral CFM can be valuable therapeutic alternative in elderly patients with moderate-to-severe bullous pemphigoid.

Characteristics of elderly patients attended at a psychiatry emergency room

Introduction

There is no general agreement on the prevalence of mental disorders in the elderly, although it is estimated that 25%. of them present psychiatric symptoms. Geriatric psychiatry is one of the most rapidly advancing fields and requires a comprehensive approach.

Objectives

To analyse the characteristics of patients older than 65 who are attended at the psychiatry emergency room.

Methods

A descriptive study was conducted among all elderly pacients seen during May 2010 at the psychiatry emergency room at Vall d’Hebron University Hospital. Clinical variables (functional status, reason to show up, medical history, diagnosis), treatment and referral at discharge were analysed.

Results

36 patients (44.4% men, mean age 75.3 years) were identified. Charlson comorbidity index was 2.08. Suicide attempts were the most frequent reason for admission (27.8%), followed by psychomotor agitation (16.7%), anxiety disorders (13.9%), delirium (13.9%), depression (11.1%), and behaviour disorders (8.3%). Concerning psychiatric antecedents 58.3% had depressive disorder and 40% reported somatic symptoms during the month prior to their consultation.

The most common diagnosis at discharge were anxiety-depressive disorders (52.7%) and delirium (16.7%). The most widely prescribed psychotropics were antipsychotics (19.4% haloperidol, 13.9% quetiapine) followed by benzodiazepines (13.9%). Referral at discharge was: 41.7% home, 13.9% midterm psychiatric units, 27.8% acute psychiatric inpatient unit and 16.7% Internal Medicine.

Conclusions

Typically, elderly patients attended at the psychiatric emergency room are diagnosed of an anxiety-depressive disorder and often present with a suicidal attempt, but only 41.7% are admitted as psychiatric inpatients.

P01-44-The e-mail as a potential therapeutic tool in patients with alcohol dependence: The patient's perspective

Introduction

The use of Internet-based communication tools has spread to multiple areas of life. E-mail is a fast and easy tool that can be used by the health care system to facilitate doctor-patient communication.

Objectives

To assess the use and value of the e-mail for communication between physician and patient, from patients’ perspective.

Aims

To evaluate the use of e-mail as a potential therapeutic tool in patients with alcohol dependence.

Methods

The sample included patients who reported to have an e-mail account at their first visit in Alcohol Unit (n = 44 of 238 patients seen during one year). 23 patients were given the contact e-mail of the Alcohol Unit, and were instructed to contact their physician, if needed, by e-mail. The rest of the sample (n = 21) could contact their physician only by phone. Six months later, the whole sample received an electronic survey measuring their satisfaction of the communication with the physician.

Results

57% patients who received the contact e-mail of the Alcohol Unit answered the survey (n = 13). Of those, 54% used e-mail to contact their physician. 71% found e-mail easy-to-use; 86% reported being satisfied with e-mail communication.

Conclusions

E-mail contact with physician was considered useful by most patients, although they report using also other contact methods, such as phone call.

Simultaneous versus delayed treatment of tobacco dependence in alcohol-dependent outpatients

INTRODUCTION

There is a high prevalence of smoking among heavy drinkers, which is often forgotten even though it has important health consequences.

AIM

To evaluate the effects that providing an intensive tobacco cessation treatment simultaneously with alcohol dependence treatment versus delayed treatment (first alcohol and 6 months later tobacco) has on alcohol and tobacco consumption.

METHODS

Ninety-two alcohol-dependent smokers were randomized into either a simultaneous group, in which treatment was given concurrently for quitting both alcohol and tobacco, or a delayed group, in which help to quit smoking was given after 6 months.

RESULTS

No differences were found in alcohol abstinence rates in time-to-first relapse or in cumulative abstinence at 6 months. Smoking cessation rates were low overall, but better at 3 months in the simultaneous group, although differences later disappeared.

DISCUSSION

Participation in a smoking cessation program does not impair alcohol outcomes, at least during the first 6 months.

Effects of platelet-derived growth factor on aqueous humor dynamics

PURPOSE

It is well known that the small GTPase RhoA modulates actin cytoskeleton and cellular contractility in the trabecular meshwork (TM). Several substances known to contract the TM reduce outflow facility, whereas cellular relaxation is commonly associated with the opposite effect. Inhibitors of the RhoA pathway are under development as antiglaucoma drugs. Here the authors investigate the role of platelet-derived growth factor (PDGF), a known activator of the Rac1 pathway, in cell cytoskeleton, outflow facility, and intraocular pressure (IOP).

METHODS

Effects of PDGF on actin cytoskeleton, Rac1, and AKT activation were tested in preconfluent and confluent bovine TM cells in culture. Rac1 and AKT/P-AKT activation were assessed by Western blot analysis. Trabecular outflow facility was measured in bovine perfused anterior segments. Changes in IOP were measured for up to 6 hours after topical application in the cornea of rabbit eyes by means of a contact tonometer.

RESULTS

In TM cells, PDGF (10 ng/mL) activated Rac1 through AKT and induced actin cytoskeleton rearrangement with lamellipodia formation. In this sense, lamellipodia formation in TM cells was prevented by NSC23766, a Rac1 inhibitor, and LY294002, a PI3K inhibitor. In perfused anterior segments, PDGF (100 ng/mL) increased trabecular outflow facility by 26%. In vivo, when topically applied to rabbit corneas, PDGF induced a 20% decrease in IOP (100 ng/mL). This reduction was concentration dependent and presented an EC(50) value of 2.7 nM.

CONCLUSIONS

PDGF, by activating the Rac1 pathway, induces cytoskeletal changes in TM cells that enhance outflow facility. Decreased IOP after PDGF application is likely caused by the facilitation of aqueous humor outflow. Rac1 pathway activation appears to be a positive modulator of outflow facility and an interesting target for decreasing IOP after ocular hypertension.

Activation of store-operated Ca(2+) channels in trabecular meshwork cells

PURPOSE

In nonexcitable cells, G(q)-coupled membrane receptor activation induces a biphasic increase in intracellular calcium ([Ca(2+)](i)) expressed as an initial IP(3)-dependent release from intracellular stores followed by a sustained Ca(2+) influx from the extracellular space that involves store-operated Ca(2+) channels (SOCs). In trabecular meshwork (TM) cells, contractile agonists such as bradykinin (BK) and endothelin-1 (ET-1) induce this type of Ca(2+) signaling. Given that trabecular outflow is modified by tissue contractility, the authors characterized SOCs and studied their participation in TM cell contractility.

METHODS

[Ca(2+)](i) was measured in cultured bovine TM cells loaded with Fura-2. Ca(2+) currents were recorded using the patch clamp technique. Cell contractility measurements were assessed by traction microscopy.

RESULTS

BK and ET-1 activate a store-operated Ca(2+) entry that was greatly reduced in the absence of extracellular Ca(2+) or by preincubation with SOC blocker 2-APB or SKF96365. Store-operated Ca(2+) currents were also activated by intracellular dialysis with IP(3) + EGTA or after stimulation with thapsigargin. Electrophysiological characterization supports the presence of Ca(2+) release-activated Ca(2+) channels (CRACs) and nonselective cation channels, of which TRPC1 and TRPC4 channels may be candidate TRPs detected in TM cells. Extracellular Ca(2+) entry through SOCs is not required for TM cell contraction in response to BK or ET-1, but it modulates this process.

CONCLUSIONS

Extracellular Ca(2+) entry in TM cells in response to agonist stimulation and store-depletion is mediated by the activation of SOCs, which do not contribute to cell contraction but which may activate regulatory mechanisms to prevent excessive contraction. CRAC and TRPC channels involved represent interesting modulators of TM function to improve aqueous humor outflow.

Profilin induces lamellipodia by growth factor-independent mechanism

Profilin has been implicated in cell motility and in a variety of cellular processes, such as membrane extension, endocytosis, and formation of focal complexes. In vivo, profilin replenish the pool of ATP-actin monomers by increasing the rate of nucleotide exchange of ADP-actin for ATP-actin, promoting the incorporation of new actin monomers at the barbed end of actin filaments. For this report, we generated a membrane-permeable version of profilin I (PTD4-PfnI) for the alteration of intracellular profilin levels taking advantage of the protein transduction technique. We show that profilin I induces lamellipodia formation independently of growth factor presence in primary bovine trabecular meshwork (BTM) cells. The effects are time- and concentration-dependent and specific to the profilin I isoform. Profilin II, the neuronal isoform, failed to extend lamellipodia in the same degree as profilin I. H133S, a mutation in the polyproline binding domain, showed a reduced ability to induce lamellipodia. H199E, mutation in the actin binding domain failed to induce membrane spreading and inhibit fetal bovine serum (FBS) -induced lamellipodia extension. Incubation with a synthetic polyproline domain peptide (GP5)3, fused to a transduction domain, abolished lamellipodia induction by profilin or FBS. Time-lapse microscopy confirmed the effects of profilin on lamellipodia extension with a higher spreading velocity than FBS. PTD4-Pfn I was found in the inner lamellipodia domain, at the membrane leading edge where it colocalizes with endogenous profilin. While FBS-induced lamellipodia formation activates Rac1, PTD4-Pfn I stimulation did not induce Rac1 activation. We propose a role of profilin I favoring lamellipodia formation by a mechanism downstream of growth factor.

Medical education in Spain: current status and new challenges

As in other countries, medical education in Spain is structured across three distinct stages: undergraduate or basic medical education; postgraduate specialized training; and continuing medical education. The aim of this article is to give an overview of the current state of these three stages, discussing the strengths and weaknesses and the challenges facing each one in the coming years, and how Spain can look to the international community to support change. We suggest that the undergraduate medical education system should be adapted to Spain's new social requirements and requires to be increasingly aligned with postgraduate training. We suggest that continuing medical education should develop its Continuous Professional Development programmes to ensure the permanent competence of Spanish medical professionals. The European Higher Education arena, as defined by the Bologna Declaration, provides many opportunities as well as a challenging situation for improving any current weaknesses in the Spanish medical education system.

Acquisition of learning outcomes by students from the Medical School of the University of Barcelona (Catalonia, Spain): a student survey

BACKGROUND

In 2001, in order to improve the curriculum, the medical school of the University of Barcelona began discussions aimed at defining specific learning outcomes for its medical graduates and, subsequently, evaluating the acquisition of these competencies.

AIM

To report the views of our medical students regarding the extent to which they have acquired the learning outcomes previously defined by the faculty.

METHOD

A questionnaire was administered to seventy final year students, who had finished all the course clerkships and they were asked to indicate on a Likert scale their perceived level of acquisition of each learning outcome.

RESULTS

Overall, the students report an adequate level of competency and consider themselves able to meet skills targets under supervision in eight of the eleven domains investigated. In three of the domains (patient management, medical information search skills, and decision-making skills and clinical reasoning and judgment) students regarded themselves as only partially competent. These results agree with the global course score of the students, according to the medical school assessment system.

CONCLUSIONS

The results will allow us to make curricular and methodological changes in order to implement a new outcome-based curriculum.

Mismatch negativity impairment associated with alcohol consumption in chronic alcoholics: A scalp current density study

Previous studies, based on amplitude and latency measurements of auditory event-related brain potentials, yielded inconclusive results about the status of mismatch negativity (MMN) in chronic alcoholics. The present study explores scalp current density (SCD) dynamics during MMN latency range in alcoholics, and correlates electrical SCD results with clinical data of the patients. SCD was computed from 30 electrodes in 16 abstinent chronic alcoholics and 16 healthy control volunteers in a paradigm on MMN elicited by duration changes. Reduced activity was observed in left frontal and right anterior and posterior temporal areas during MMN in alcoholics. Alcohol consumption correlated negatively with SCD intensity in these regions. Delayed activation was observed in the left posterior temporal area in the patients. Alcohol abstinence duration correlated positively with SCD intensity in this region. These results point to an impairment of automatic brain processing mechanisms associated with auditory change detection in chronic alcoholism. The present results suggest a reorganization of the computational neurodynamics of automatic auditory change detection linked to the amount of alcohol consumed in abstinent chronic alcoholics.

Identification and functional characterization of ClC-2 chloride channels in trabecular meshwork cells

In the eye, trabecular meshwork (TM) cell volume may be an important determinant of aqueous humor outflow. Among their functions, ClC-2 chloride channels are thought to be involved in regulation of cellular volume and intracellular [Cl(-)]. We characterized the properties and modulation of an inwardly rectifying chloride current activated in these cells. Patch-clamp recordings revealed inwardly rectifying chloride currents activated by membrane hyperpolarization in primary cultures of both bovine (BTM) and human (HTM) TM cells. Electrophysiological properties and anion permeability sequence (Cl(-)>Br(-)>I(-)>F(-)) were in agreement with previous data for ClC-2 in other cells. The currents were blocked by Cd(2+) and enhanced by extracellular acidification, 8Br-cAMP and cell swelling, while extracellular alkalinization decreased them. RT-PCR experiments using total RNA revealed the molecular expression of ClC-2 channels. Previously we reported the involvement of swelling-activated chloride channels (Cl(swell)) and Ca(2+)-activated K(+) channels (BK(Ca)) in cell volume and outflow facility regulation. However, in the present analysis, cell volume experiments in calcein-loaded cells and outflow facility studies performed in bovine anterior segments revealed that ClC-2 channels do not make a significant contribution to the recovery of cellular volume or to the regulation of the outflow facility. Nevertheless, ClC-2 modulation by different stimuli may contribute to intracellular [Cl(-)] regulation and other cellular functions yet to be determined in the TM.

[Group psychotherapy with young alcoholics: specialization or integration?]

INTRODUCTION

Group therapy (GT) is widely used in the treatment of alcoholism. Nevertheless, few data are available on the inclusion criteria for specific individual, as well as on specific group, techniques for the management of some types or groups of patients with homogeneous characteristics.

METHOD

Compliance with group therapy has been analyzed in a sample of 459 alcoholics under 36 years of age, 303 of whom were placed in specific GT for young people (Y groups) and 156 were allocated in standard GT (NY) groups.

RESULTS

Similar rates of discharge (16.8% vs 18.6%), withdrawals and drop-outs (63.4% vs 61.5%) of patients have been found in both groups. No differences were found in the survival function of time of compliance adjusted for gender and age (Y: 27.2%, and NY: 33.3% at one year, and Y: 18.4%, and NY: 21% at 2 years).

CONCLUSIONS

There is no scientific evidence to support the use of Y groups in the treatment of young alcoholics. On the other hand, the possibility still exists that the use of groups with composition, techniques and specific objectives may provide improvement in compliance and in the therapeutic results as long as they adequately identify the characteristics of the patients who may benefit from a homogeneous treatment.

Use of transduction proteins to target trabecular meshwork cells: outflow modulation by profilin I

PURPOSE

Fusion proteins containing a protein transduction domain (PTD4) are able to cross biological membranes. We tested the applicability of the protein transduction method for study of the aqueous humor trabecular outflow pathway by targeting the actin cytoskeleton, which is known to be involved in outflow facility regulation.

METHODS

Expression vectors useful for generating fusion proteins with the PTD4 domain and the actin-binding protein Profilin I were constructed. The transductional and functional properties of these proteins were tested in bovine trabecular meshwork cells in culture. The effects of PTD4-Profilin I on outflow facility were evaluated in perfused bovine anterior segments. PTD4-beta-galactosidase was used to visually check correct delivery of fusion proteins to trabecular meshwork cells.

RESULTS

The fusion proteins generated were characterized by western blot. Immunocytochemistry experiments showed intracellular staining for PTD4-Profilin I in trabecular meshwork cells in culture. The fusion protein was found in the cytoplasm associated with actin filaments and in the leading edge of the cellular membrane. In contrast, control Profilin I, without the PTD4 domain, was unable to cross the cell membrane. In perfused anterior segments, 2 microM PTD4-Profilin I increased trabecular outflow facility in a reversible manner, while Profilin I had no significant effect. Anterior segments perfused with PTD4-beta-galactosidase showed positive staining in the trabecular meshwork tissue.

CONCLUSIONS

Protein transduction technology is a valuable tool for targeting trabecular meshwork tissue, not only for performing physiological studies, but also as a potential drug-delivery method. Profilin I action on the actin cytoskeleton further reinforces the importance of this structure in outflow facility regulation.

Genomic and functional characterization of stellate cells isolated from human cirrhotic livers

BACKGROUND/AIMS

Hepatic stellate cells (HSCs) are believed to participate in liver fibrogenesis and portal hypertension. Knowledge on human HSCs is based on studies using HSCs isolated from normal livers. We investigated the phenotypic, genomic and functional characteristics of HSCs from human cirrhotic livers.

METHODS

HSC were obtained from normal and cirrhotic human livers. Cells were characterized by immunocytochemistry and gene microarray analysis. Cell proliferation, Ca(2+) changes and cell contraction were assessed by 3H-thymidine incorporation and by using an epifluorescence microscope.

RESULTS

HSCs freshly isolated from human cirrhotic livers showed phenotypical features of myofibroblasts. These features were absent in HSCs freshly isolated from normal human livers and become prominent after prolonged culture. HSCs from cirrhotic human livers markedly express genes involved in fibrogensis, inflammation and apoptosis. HSCs from normal livers after prolonged culture preferntially expressed genes related to fibrogenesis and contractility. Agonists induced proliferation, Ca(2+) increase and cell contraction in HSCs isolated from human cirrhotic livers. Response to agonists was more marked in culture-activated HSCs and was not observed in HSCs freshly isolated from normal livers.

CONCLUSIONS

HSCs from human cirrhotic livers show fibrogenic and contractile features. However, the current model of HSCs activated in culture does not exactly reproduce the activated phenotype found in cirrhotic human livers.