Psilocybin for dementia prevention? The potential role of psilocybin to alter mechanisms associated with major depression and neurodegenerative diseases

Major depression is an established risk factor for subsequent dementia, and depression in late life may also represent a prodromal state of dementia. Considering current challenges in the clinical development of disease modifying therapies for dementia, the focus of research is shifting towards prevention and modification of risk factors to alter the neurodegenerative disease trajectory. Understanding mechanistic commonalities underlying affective symptoms and cognitive decline may reveal biomarkers to aid early identification of those at risk of progressing to dementia during the preclinical phase of disease, thus allowing for timely intervention. Adult hippocampal neurogenesis (AHN) is a phenomenon that describes the birth of new neurons in the dentate gyrus throughout life and it is associated with spatial learning, memory and mood regulation. Microglia are innate immune system macrophages in the central nervous system that carefully regulate AHN via multiple mechanisms. Disruption in AHN is associated with both dementia and major depression and microgliosis is a hallmark of several neurodegenerative diseases. Emerging evidence suggests that psychedelics promote neuroplasticity, including neurogenesis, and may also be immunomodulatory. In this context, psilocybin, a serotonergic agonist with rapid-acting antidepressant properties has the potential to ameliorate intersecting pathophysiological processes relevant for both major depression and neurodegenerative diseases. In this narrative review, we focus on the evidence base for the effects of psilocybin on adult hippocampal neurogenesis and microglial form and function; which may suggest that psilocybin has the potential to modulate multiple mechanisms of action, and may have implications in altering the progression from major depression to dementia in those at risk.

Pedicled chimeric superficial circumflex iliac artery perforator (SCIP) flap with external oblique fascia for vesicocutaneous bladder fistula repair: A case report and literature review on the utility of pedicled chimeric SCIP

Following its initial description by Koshima in 2004, the superficial circumflex iliac artery perforator (SCIP) flap has become a ubiquitous and extremely useful flap in coverage of defects whereby bulkiness must be avoided. It also allows direct closure and concealment of the donor site. Its use as a free tissue transfer has been demonstrated by various surgeons globally. Nevertheless, there are few cases illustrating the utility of the pedicled SCIP flap in the reconstruction of lower abdominal defects. We present a case of a pedicled SCIP flap utilized as a chimeric flap incorporating external oblique muscle fascia on a deep branch along with the typical fasciocutaneous component based on the superficial branch to cover the suprapubic defect after vesicocutaneous fistula repair. We thereafter report on the literature of pedicled chimeric SCIP flap for locoregional reconstruction. A 26-year-old female was referred to the Plastic and Reconstructive Surgery unit after suffering a functional bladder outlet obstruction necessitating the creation of a urinary stoma. Subsequently, stoma obstruction occurred, and a suprapubic catheter was performed that was complicated by infection and resulted in the development of a vesicocutaneous fistula. Accordingly, the urological surgeons were planning surgical closure of the suprapubic vesicocutaneous defect, measuring 5 × 4 cm. A pedicled SCIP flap was designed to match the defect size; and raised as a chimeric flap with external oblique muscle fascia based on the deep branch, along with the fasciocutaneous component based on the superficial branch. The external oblique fascial component was used to secure the suture line of fistula repair, over which the fasciocutaneous component was inset, effectively double breasting the fistula repair and full thickness lower abdominal defect. The patient had an unremarkable postoperative recovery and has since been followed up in the outpatient setting without complication for the past 24 months. Robust coverage of the suprapubic defect was reliably achieved and no further fistulation has occurred. This case illustrates that a pedicled SCIP flap can be harvested as a chimeric flap and used to reliably cover defects in the infra-umbilical region.

Consistent patterns of common species across tropical tree communities

Trees structure the Earth's most biodiverse ecosystem, tropical forests. The vast number of tree species presents a formidable challenge to understanding these forests, including their response to environmental change, as very little is known about most tropical tree species. A focus on the common species may circumvent this challenge. Here we investigate abundance patterns of common tree species using inventory data on 1,003,805 trees with trunk diameters of at least 10 cm across 1,568 locations1-6 in closed-canopy, structurally intact old-growth tropical forests in Africa, Amazonia and Southeast Asia. We estimate that 2.2%, 2.2% and 2.3% of species comprise 50% of the tropical trees in these regions, respectively. Extrapolating across all closed-canopy tropical forests, we estimate that just 1,053 species comprise half of Earth's 800 billion tropical trees with trunk diameters of at least 10 cm. Despite differing biogeographic, climatic and anthropogenic histories7, we find notably consistent patterns of common species and species abundance distributions across the continents. This suggests that fundamental mechanisms of tree community assembly may apply to all tropical forests. Resampling analyses show that the most common species are likely to belong to a manageable list of known species, enabling targeted efforts to understand their ecology. Although they do not detract from the importance of rare species, our results open new opportunities to understand the world's most diverse forests, including modelling their response to environmental change, by focusing on the common species that constitute the majority of their trees.

Antidepressant and antipsychotic side-effects and personalised prescribing: a systematic review and digital tool development

BACKGROUND

Side-effects of psychiatric medication impair quality of life and functioning. Furthermore, they contribute to morbidity, mortality, stigma, and poor treatment concordance resulting in relapse of psychiatric illness. Guidelines recommend discussing side-effects with patients when making treatment decisions, but a synthesis of antidepressant and antipsychotic side-effects to guide this process is missing, and considering all side-effects is a complex, multidimensional process. We aimed to create comprehensive databases of antipsychotic and antidepressant side-effects, and a digital tool to support database navigation.

METHODS

To create the databases, we did an umbrella review of Embase, PsycINFO, and MEDLINE from database inception to June 26, 2023. We included meta-analyses of randomised controlled trials examining antipsychotic monotherapy in the treatment of schizophrenia or antidepressant monotherapy in the treatment of major depressive disorder. We included meta-analyses in adults (aged ≥18 years) that assessed drugs with a common comparator. The search was complemented by a review of national and international guidelines and consensus statements for the treatment of major depressive disorder and schizophrenia in adults. Effect sizes for antipsychotic and antidepressant side-effects were extracted from meta-analyses examining the largest number of drugs. In cases of incomplete meta-analytic coverage, data were imputed on the basis of guideline-derived ordinal rankings or, if imputation was not possible, ordinal scores were extracted. Both meta-analytic and ordinal outcomes were normalised to provide values between 0 and 1. We then constructed a digital tool, the Psymatik Treatment Optimizer, to combine the side-effect databases with side-effect concerns of an individual user, to enable users to select side-effects of concern and the relative degree of concern for each side-effect. Concern weightings and the side-effect databases are synthesised via a multicriteria decision analysis method (technique for order of preference by similarity to ideal situation, or TOPSIS).

FINDINGS

Of 3724 citations, 14 articles containing 68 meta-analyses of individual side-effects met inclusion criteria. After review of 19 guidelines, seven provided ordinal data. Antipsychotic data were extracted from five studies (11 meta-analyses, n=65 594 patients) and four guidelines, and antidepressant data were extracted from three guidelines. The resultant databases included data on 32 antipsychotics (14 side-effects) and 37 antidepressants (nine side-effects). The databases highlighted the clinical dilemma associated with balancing side-effects, with avoidance of one side-effect (eg, weight gain for antipsychotics) increasing the risk of others (eg, akathisia). To aid with this dilemma, the Psymatik Treatment Optimizer synthesises the side-effect databases with individual user-defined concern weights. After computing up to 5851 pairwise comparisons for antidepressants and 5142 pairwise comparisons for antipsychotics, Psymatik ranks treatments in order of preference for the individual user, with the output presented in a heatmap.

INTERPRETATION

By facilitating collaborative, personalised, and evidence-based prescribing decisions, the side-effect databases and digital application supports care delivery that is consistent with international regulatory guidance for the treatment of schizophrenia and depression, and it therefore has promise for informing psychiatric practice and improving outcomes.

FUNDING

National Institute for Health and Care Research, Maudsley Charity, Wellcome Trust, Medical Research Council.

Data-Driven Taxonomy for Antipsychotic Medication: A New Classification System

BACKGROUND

Globally, there are more than 25 licensed antipsychotic medications. Antipsychotics are commonly described as either typical or atypical, but this dichotomous classification does not reflect the diversity of their pharmacological and clinical profiles. There is a need for a data-driven antipsychotic classification scheme suitable for clinicians and researchers that maps onto both pharmacological and clinical effects. Receptor affinity provides one starting point for such a scheme.

METHODS

We analyzed affinities of 27 antipsychotics for 42 receptors from 3325 in vitro receptor binding studies. We used a clustering algorithm to group antipsychotics based on receptor affinity. Using a machine learning model, we examined the ability of this grouping to predict antipsychotic-induced clinical effects quantified according to an umbrella review of clinical trial and treatment guideline data.

RESULTS

Clustering resulted in 4 groups of antipsychotics. The predominant receptor affinity and clinical effect "fingerprints" of these 4 groups were defined as follows: group 1, muscarinic (M2-M5) receptor antagonism (cholinergic and metabolic side effects); group 2, dopamine (D2) partial agonism and adrenergic antagonism (overall low side-effect burden); group 3, serotonergic and dopaminergic antagonism (overall moderate side-effect burden); and group 4, dopaminergic antagonism (extrapyramidal side effects and hyperprolactinemia). Groups 1 and 4 were more efficacious than groups 2 and 3. The classification was shown to predict out-of-sample clinical effects of individual drugs.

CONCLUSIONS

A receptor affinity-based grouping not only reflects compound pharmacology but also detects meaningful clinical differences. This approach has the potential to benefit both patients and researchers by guiding treatment and informing drug development.

Implementing gradual, hyperbolic tapering of long-acting injectable antipsychotics by prolonging the inter-dose interval: an in silico modelling study

Gradual, hyperbolic tapering has been proposed as a method to reduce the risk of withdrawal effects and potential relapse of an underlying condition by minimising disruption of existing equilibria. We applied hyperbolic tapering principles in silico to long-acting aripiprazole to generate regimens for withdrawal in clinical practice. We derived thresholds for taper rates using existing studies and consensus. Using pharmacokinetic data for aripiprazole long-acting injectable antipsychotic (ALAI), we conducted in silico modelling to examine the impact of abrupt cessation of long-acting injectable antipsychotic (LAI) medication and the effect of prolonging inter-dose interval on plasma aripiprazole levels and consequent D2 occupancy. We also modelled transitions from LAI medication to oral medication. Regimens were designed to afford a rate of reduction between 5 and 12.5 percentage points of D2 occupancy per month. Abrupt discontinuation of ALAI was shown to lead to a maximal D2 occupancy reduction of 16.8 percentage points per month; prolongation of the inter-dose interval of ALAI produced a slower reduction. Specifically, hyperbolic tapering was afforded by prolongation of a 400 mg ALAI inter-dose interval from 4 to 7 weeks, before reducing the dose to 300 mg ALAI. This could then be administered at up to 4-week (for 6% maximal D2 occupancy change), 6-week (9% change) or 7-week (11% change) intervals. Switching to oral medication - 5, 2.5 and 1.25 mg for the three regimens, respectively - is required for ALAI to complete full cessation to prevent too rapid a reduction in D2 occupancy. Oral medication should probably be maintained at a consistent dose for 3-6 months before further reductions to account for residual LAI being concurrently eliminated. Hyperbolic dose tapering is possible with ALAI through prolongation of the inter-dose interval and may reduce the risk of relapse compared to abrupt discontinuation of LAI medication.

Evidence of Electron Heating by Alpha Particles in JET Deuterium-Tritium Plasmas

The fusion-born alpha particle heating in magnetically confined fusion machines is a high priority subject for studies. The self-heating of thermonuclear fusion plasma by alpha particles was observed in recent deuterium-tritium (D-T) experiments on the joint European torus. This observation was possible by conducting so-called "afterglow" experiments where transient high fusion yield was achieved with neutral beam injection as the only external heating source, and then termination of the heating at peak performance. This allowed the first direct evidence for electron heating of plasmas by fusion-born alphas to be obtained. Interpretive transport modeling of the relevant D-T and reference deuterium discharges is consistent with the alpha particle heating observation.

CAPTURE ALS: the comprehensive analysis platform to understand, remedy and eliminate ALS

The absence of disease modifying treatments for amyotrophic lateral sclerosis (ALS) is in large part a consequence of its complexity and heterogeneity. Deep clinical and biological phenotyping of people living with ALS would assist in the development of effective treatments and target specific biomarkers to monitor disease progression and inform on treatment efficacy. The objective of this paper is to present the Comprehensive Analysis Platform To Understand Remedy and Eliminate ALS (CAPTURE ALS), an open and translational platform for the scientific community currently in development. CAPTURE ALS is a Canadian-based platform designed to include participants' voices in its development and through execution. Standardized methods will be used to longitudinally characterize ALS patients and healthy controls through deep clinical phenotyping, neuroimaging, neurocognitive and speech assessments, genotyping and multisource biospecimen collection. This effort plugs into complementary Canadian and international initiatives to share common resources. Here, we describe in detail the infrastructure, operating procedures, and long-term vision of CAPTURE ALS to facilitate and accelerate translational ALS research in Canada and beyond.

Instructional review of key factors to achieve successful outcomes when using low-intensity pulsed ultrasound in fracture repair

Low-intensity pulsed ultrasound (LIPUS) treatment of fractures has been available to the orthopaedic community for nearly three decades; however, it is still considered an experimental treatment by some clinicians, even though there is a wealth of clinical data. Based on the evaluation of clinical trial data, we have established key criteria which can lead to LIPUS success and avoid failure. These are fracture gap size and stability, accurate transducer placement and minimum treatment number. However, from a clinician's view, the correct attitude to treatment must be observed, and this has also been discussed. It is hoped, armed with this new evaluation of the clinical data, that clinicians can treat patients with LIPUS more effectively, resulting in fewer failures of treatment.

Selective border permeability: Governing complex environmental issues through and beyond COVID-19

COVID-19 has changed the permeability of borders in transboundary environmental governance regimes. While borders have always been selectively permeable, the pandemic has reconfigured the nature of cross-border flows of people, natural resources, finances and technologies. This has altered the availability of spaces for enacting sustainability initiatives within and between countries. In Southeast Asia, national governments and businesses seeking to expedite economic recovery from the pandemic-induced recession have selectively re-opened borders by accelerating production and revitalizing agro-export growth. Widening regional inequities have also contributed to increased cross-border flows of illicit commodities, such as trafficked wildlife. At the same time, border restrictions under the exigencies of controlling the pandemic have led to a rolling back and scaling down of transboundary environmental agreements, regulations and programs, with important implications for environmental democracy, socio-ecological justice and sustainability. Drawing on evidence from Southeast Asia, the article assesses the policy challenges and opportunities posed by the shifting permeability of borders for organising and operationalising environmental activities at different scales of transboundary governance.

Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle

Ankle fractures are a common presentation to orthopaedic surgeons, with the lateral malleolus involved in 86% of cases. A soft tissue injury can be a concomitant feature of these injuries as a result of the primary injury or following secondary wound breakdown. The peroneus brevis muscle flap provides a reliable and robust option to cover the distal third of the lower limb. With an understanding of the anatomy and cautious dissection during periosteal elevation, the perforating vessels supplying the peroneus brevis can be preserved ensuring that a valuable reconstructive option is available.

Assessment of emergency department staff awareness, access and utilisation of advance care directives and goals of care: A cross-sectional survey

BACKGROUND

Emergency department staff awareness, access and implementation of advance care directives and goals of care documents and the related patient consent processes are important but not well understood.

METHODS

A cross-sectional survey using purposive sampling was undertaken at a tertiary hospital's Emergency Department from 15th March to 26th April 2021. Participants were recruited through online platforms. Pre-validated questionnaires were distributed by email or as QR codes on bulletin boards. Data collected included staff: demographics, knowledge, access and implementation of advance care directives and goals of care documentation.

RESULTS

One hundred thirty-four (28%) of 476 targeted participants responded with nursing forming largest group. Results showed that previous attendance of advance care planning education was low at 20%. Familiarity with advance care directive documentations was only 19% while with goals of care document was average. 61 (48%) respondents reported ease of accessing electronic documents and 21 (19%) reported feeling very comfortable discussing and setting goals of care with patients (p = <0.01).

CONCLUSIONS

Staff awareness of advance care directive was poor, while awareness of goals of care was average. There was no association between advance care directives awareness and staff age group, gender, length of: - professional practice, practice at the study site.

Regular medication use by active scuba divers with a declared comorbid medical condition and victims of scuba and snorkelling-related fatalities

INTRODUCTION

The aim of this study was to describe the nature of regular medications taken by active comorbid scuba divers (having a declared medical comorbidity) and scuba divers and snorkellers who died following a diving incident.

METHODS

We undertook a retrospective, observational study from July to October, 2020. Data on 268 active comorbid divers were obtained through a 2013 survey of Divers Alert Network Asia-Pacific members. Data on 126 deceased scuba divers and 175 deceased snorkellers were obtained predominantly from 2001-2013 reports to Australian State Coronial Services.

RESULTS

The active comorbid divers were significantly older, less likely to be male, and more likely to be taking one or more medications than the two deceased subject groups (P < 0.001). Cardiovascular, endocrine and psychotropic medications accounted for 53.4%, 9.9% and 6.4% of all medications taken, respectively. Almost one tenth of the deceased divers took at least one psychotropic medication, a proportion significantly greater than the other groups (P = 0.01).

CONCLUSIONS

Medication use among active comorbid divers is common which likely reflects their declared medical condition. Nevertheless, they appear to be diving relatively safely, often with conditions once thought to be absolute contradictions to scuba diving. The deceased divers took significantly more psychotropic medications. It is possible that their underlying psychological/psychiatric conditions rendered them more at risk of a diving incident. Increased vigilance for psychological conditions may need to be considered during diving medical examinations.

Vitamin D in the time of the coronavirus (COVID-19) pandemic - a clinical review from a public health and public mental health perspective

Individuals with serious mental disorders (SMD) may have a higher risk of vitamin D (VIT-D) deficiency. They also experience higher mortality because of coronavirus disease 2019 (COVID-19) infection. Therefore, we have conducted a comprehensive review to examine the significance of VIT-D for public health and public mental health during the ongoing COVID-19 pandemic. This review had three specific aims, from a global perspective to (a) create a profile of VIT-D and review the epidemiology of VIT-D deficiency, (b) explore VIT-D deficiency as risk factor for SMD and COVID-19 infections and (c) examine the effectiveness of VIT-D supplementation for both conditions. We found that, in terms of SMD, the evidence from laboratory and observational studies points towards some association between VIT-D deficiency and depression or schizophrenia. Mendelian randomisation studies, however, suggest no, or reverse, causality. The evidence from intervention studies is conflicting. Concerning COVID-19 infection, on proof of principle, VIT-D could provide a plausible defence against the infection itself and against an adverse clinical course. But data from observational studies and the first preliminary intervention studies remain conflicting, with stronger evidence that VIT-D may mitigate the clinical course of COVID-19 infection rather than the risk of infection in the first place. From a public health and public mental health point of view, based on the currently limited knowledge, for individuals with SMD, the benefits of VIT-D optimisation through supplementation seem to outweigh the risks. VIT-D supplementation, however, should not substitute for vaccination or medical care for COVID-19 infection.

The CANBACK trial: a randomised, controlled clinical trial of oral cannabidiol for people presenting to the emergency department with acute low back pain

OBJECTIVE

To assess the analgesic efficacy and safety of single-dose oral cannabidiol (CBD) as an adjunct to standard care for patients presenting to an emergency department with acute low back pain.

DESIGN

Randomised, double blinded, placebo-controlled clinical trial.

SETTING

The tertiary emergency department of Austin Hospital, Melbourne.

PARTICIPANTS

Patients who presented with acute, non-traumatic low back pain between 21 May 2018 and 13 June 2019.

INTERVENTION

One hundred eligible patients were randomised to receiving 400 mg CBD or placebo in addition to standard emergency department analgesic medication.

MAIN OUTCOME MEASURES

Pain score two hours after administration of study agent, on a verbal numerical pain scale (range, 0-10). Secondary outcomes were length of stay, need for rescue analgesia, and adverse events.

RESULTS

The median age of the 100 participants was 47 years (IQR, 34-60 years); 44 were women. Mean pain scores at two hours were similar for the CBD (6.2 points; 95% CI, 5.5-6.9 points) and placebo groups (5.8 points; 95% CI, 5.1-6.6 points; absolute difference, -0.3 points; 95% CI, -1.3 to 0.6 points). The median length of stay was 9.0 hours (IQR, 7.4-12 hours) for the CBD group and 8.5 hours (IQR, 6.5-21 hours) for the placebo group. Oxycodone use during the four hours preceding and the four hours after receiving CBD or placebo was similar for the two groups, as were reported side effects.

CONCLUSION

CBD was not superior to placebo as an adjunct medication for relieving acute non-traumatic low back pain in the emergency department.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618000487213 (prospective).

An evaluation of the variation and underuse of clozapine in the United Kingdom

BACKGROUND

Clozapine is the only licensed treatment for treatment refractory schizophrenia. Despite this, it remains grossly underused relative to the prevalence of refractory schizophrenia. The extent of underuse and the degree of regional variation in prescribing in the United Kingdom is unknown. It is also unclear, how the UK compares with other European countries in rates of clozapine prescribing.

METHODS

We obtained data relating to all clozapine prescribing in the UK from the relevant clozapine registries. We examined regional variation in clozapine use across England, corrected for the known prevalence of severe mental illness (SMI). We also compared the UK rate of clozapine use per 100,000 population to that described in other European countries.

FINDINGS

There is substantial variation in clozapine prescribing across different regions of England and only about a third of potentially eligible patients were prescribed the drug in the UK. Clozapine prescribing rate in the UK was lower than in several European countries.

INTERPRETATION

There is clear regional inequity in access to the most effective treatment in refractory schizophrenia in England. Strategies to increase clozapine use, by overcoming both real and perceived barriers, are urgently necessary to reduce treatment inequity for patients with refractory schizophrenia.

A prospective, randomized, double-blind trial of intravenous chlorpromazine versus intravenous prochlorperazine for the treatment of acute migraine in adults presenting to the emergency department

OBJECTIVE

To compare the efficacy of intravenous chlorpromazine versus intravenous prochlorperazine for the treatment of acute migraine in adults presenting to the emergency department (ED).

BACKGROUND

Migraine is a common, incapacitating neurological condition. Although chlorpromazine and prochlorperazine are known to be safe, efficacious treatments for migraine, they have never been directly compared.

DESIGN

We performed a prospective, randomized, double-blind clinical trial at a tertiary hospital in Melbourne, Australia. Adults aged 18-65 years, who presented with migraine, were eligible for recruitment. Sixty-six patients were randomized to either chlorpromazine 12.5 mg or prochlorperazine 12.5 mg, both infused in 500 ml of sodium chloride 0.9% over 30 min. Headache severity score, nausea severity score, and the presence of photophobia and phonophobia were assessed at 0, 30, 60, and 120 min. Adverse effects and the need for rescue therapy were recorded. The primary outcome was a reduction in headache severity score from baseline at 60 min post-commencement of the study medicine infusion.

RESULTS

Sixty-five patients were included in the analysis. There was a median reduction in headache severity score at 60 min of 3.0 (interquartile range 1.0-4.0) in the chlorpromazine arm versus 2.0 (1.0-4.0) in the prochlorperazine arm (median difference -0.5 (95% confidence interval, -1.9 to 0.9)). We saw no evidence of a difference in secondary outcomes at 30, 60, or 120 min. Side effects were reported in 16/32 (50%) patients in the chlorpromazine group versus 7/33 (21%) in the prochlorperazine group (p = 0.020). Rescue therapy was required in 7/32 (22%) patients in the chlorpromazine group versus 12/33 (36%) in the prochlorperazine group (p = 0.277).

CONCLUSIONS

Both chlorpromazine and prochlorperazine are efficacious treatments for acute migraine in adult patients presenting to the ED. This trial found no evidence of superiority of either agent over the other. Caution should be used when prescribing these medicines in the borderline hypotensive patient; in that circumstance, prochlorperazine should be preferentially used.

Intramuscular midazolam, olanzapine, or haloperidol for the management of acute agitation: A multi-centre, double-blind, randomised clinical trial

BACKGROUND

The safety and effectiveness of intramuscular olanzapine or haloperidol compared to midazolam as the initial pharmacological treatment for acute agitation in emergency departments (EDs) has not been evaluated.

METHODS

A pragmatic, randomised, double-blind, active-controlled trial was conducted from December 2014 to September 2019, in six Hong Kong EDs. Patients (aged 18-75 years) with undifferentiated acute agitation requiring parenteral sedation were randomised to 5 mg intramuscular midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57). Primary outcomes were time to adequate sedation and proportion of patients who achieved adequate sedation at each follow-up interval. Sedation levels were measured on a 6-level validated scale (ClinicalTrials.gov Identifier: NCT02380118).

FINDINGS

Of 206 patients randomised, 167 (mean age, 42 years; 98 [58·7%] male) were analysed. Median time to sedation for IM midazolam, olanzapine, and haloperidol was 8·5 (IQR 8·0), 11·5 (IQR 30·0), and 23·0 (IQR 21·0) min, respectively. At 60 min, similar proportions of patients were adequately sedated (98%, 87%, and 97%). There were statistically significant differences for time to sedation with midazolam compared to olanzapine (p = 0·03) and haloperidol (p = 0·002). Adverse event rates were similar across the three arms. Dystonia (n = 1) and cardiac arrest (n = 1) were reported in the haloperidol group.

INTERPRETATION

Midazolam resulted in faster sedation in patients with undifferentiated agitation in the emergency setting compared to olanzapine and haloperidol. Midazolam and olanzapine are preferred over haloperidol's slower time to sedation and potential for cardiovascular and extrapyramidal side effects.

FUNDING

Research Grants Council, Hong Kong.

Effective conspecific communication with aberrant calls in the common cuckoo (Cuculus canorus)

Abstract

The obligate brood parasitic common cuckoo (Cuculus canorus) is best known for its two-note “cu-coo” call, which is uttered repeatedly by adult males during the breeding season. This call advertises the male’s claim for his territory. A rare, aberrant version (“cu-kee”) was discovered in a population of cuckoos in central Hungary. In a playback experiment, we simulated conspecific territorial intrusions using either aberrant call sequences or normal calls (as control). Cuckoos responded to both calls similarly by approaching the speaker, flying around it several times, and perching on nearby trees. To identify the role of each note of these cuckoo calls, we also played sequences of the first (“cu”) or second (“coo” or “kee”) notes of the calls. Territorial males responded to first notes at similarly high frequencies as to each of the full calls, whereas responses toward either second note type were nearly absent. Thus, the first notes of both typical and aberrant cuckoo calls contain sufficient information to recognize conspecific males and the novel calls did not reduce the efficiency of male-male communication in cuckoos because the aberration occurred in the less functional second note.

Significance statement

Birds use songs and calls to communicate with each other, including advertising their territories to keep competitors away. However, when the acoustic signal is atypical and distorted, the receiver individual may not process it correctly. Common cuckoos recognize a territorial intruder by their well-known “cu-coo” calls. We studied a rare, aberrant version of the common cuckoo call (“cu-kee”), which differed from the normal call in the second note of the two-partite call. However, cuckoos responded similarly to both of the normal and aberrant calls in a playback experiment. When the first or second parts of the different calls were played separately, only the first part of the cuckoo calls was effective in eliciting territorial defence. Consequently, the aberrant second note did not reduce cuckoos’ communication efficiency.

The Effect of the Consent Process on Patient Satisfaction With Pain Management: A Randomized Controlled Trial

STUDY OBJECTIVE

We aim to determine whether the timing and context of informed consent affects the subjective outcome of patient satisfaction with pain management.

METHODS

We conducted a randomized controlled trial in a single emergency department (ED). Patients aged 18 years or older with a triage pain score of greater than or equal to 4 provided consent to participate in a pain management study. They were randomized to consent in the ED or at follow-up. All patients were followed up at 48 hours post-ED discharge. Patients who consented at follow-up were unaware of the study until cold called. The primary outcome was patient satisfaction with pain management. Secondary analyses examined effects on follow-up and participation rates. Variables associated with patients' being very satisfied were determined with multivariate logistic regression.

RESULTS

Outcome data were obtained on 655 of 825 patients enrolled (79.4%). Patients who provided consent at follow-up were less likely to be very satisfied compared with those who consented in the ED (difference in proportions 11.5%; 95% confidence interval 3.5 to 19.4). Follow-up and participation rates did not differ between the groups. Patients who received pain advice and adequate analgesia (both as defined in this study) were more likely to be very satisfied (odds ratio 5.18, 95% confidence interval 2.82 to 9.52; and odds ratio 1.54, 95% confidence interval 1.07 to 2.22, respectively).

CONCLUSION

The timing and context of informed consent significantly affect the subjective outcome of patient satisfaction, and this should be considered during study design. Clinicians should strive to provide pain advice and adequate analgesia to maximize their patients' satisfaction.

Positive views on antipsychotic long-acting injections: results of a survey of community patients prescribed antipsychotics

BACKGROUND

We aimed to assess patients' views about antipsychotic long-acting injections (LAIs).

METHODS

We interviewed patients prescribed an antipsychotic (oral or LAI) in our community teams. In a subanalysis, responses were analysed for differences between patients currently receiving an LAI and those prescribed only oral medication.

RESULTS

In total, 226 patients (57%) completed the study questionnaire. The majority agreed that LAIs ensured delivery of the right amount of medication and protection against hospital admissions (57% and 60%, respectively). A minority of participants were more concerned than not about the use of a needle (46%), pain from injection (48%) and the need to travel to receive the injection (34%). A majority expressed a preference for injection site (deltoid or gluteal) (65%) and clinic location (69%). A higher proportion of patients currently receiving an LAI compared with those prescribed oral medication thought an LAI was beneficial because this formulation obviated the need to: swallow tablets (63% versus 41%; p = 0.0013), remember to take tablets daily (75% versus 51%; p = 0.0004), remember tablets when away from home (72% versus 49%; p = 0008). Current LAI users were more likely than those on oral treatment to agree that LAIs keep patients out of hospital (76% versus 44%; p = 0.0001) and that the injection ensured delivery of the right amount of medication (71% versus 44%; p = 0.0002). Women were more likely than men to prefer administration by a clinician of the same gender (34% versus 12%; p = 0.0001).

CONCLUSIONS

In our study, a greater proportion of patients prescribed an LAI regarded LAIs as beneficial compared with those on oral medication.

Ethnopharmacology†

BACKGROUND

Ethnopharmacology relates to the study of substances used medicinally by different ethnic or cultural groups or handling of, drugs-based ethnicity or pharmacogenetics.

AIMS

To review the key aspects of ethnopharmacology.

METHOD

This lecture gives an overview of the relationship between geography, culture, pharmacogenomics and prescribing.

RESULTS

Although the majority of antipsychotics, antidepressants and mood-stabilisers are widely and cheaply available in generic forms, prescription rates can vary. Clozapine is one such example with prescribing-rates ranging from less than 10 patients per 100,000 people to nearly 180 patients/100,000 people. Pharmacogenetic studies of antipsychotics and antidepressants concern gene polymorphisms that may affect both, pharmacodynamic or pharmacokinetic properties. Considerable genetic and ethnic variability has been seen for the P450 microsomal enzymes CYP 2D6 and 1A2.

CONCLUSIONS

With accelerated global mobility and increased understanding of medicinal substances at molecular level, understanding of ethnopharmacology will become increasingly important in routine clinical practice.

Reducing the stigma of long acting injectable antipsychotics - current concepts and future developments

BACKGROUND

Long acting injectable antipsychotics (LAI-APs) are considered a major advance in psychiatric treatment concerning treatment adherence and outcomes. Yet, both, doctors and patients remain sceptical.

AIM

To explain the rationale for using LAI-APs, review their effectiveness and explore barriers to use.

METHOD

Clinical overview of LAI-APs from the patient and doctor's perspective.

RESULTS

LAI-APs were developed to increase adherence to treatment, thereby improving treatment outcomes. LAI-APs may reduce the risk of relapse and hospitalisation. Yet, the evidence from the few meta-analyses available remains weak. Both patients and doctors may associate LAI-APs with stigma and coercion. Current means of improving adherence include more focus on the therapeutic relationship, better information, adverse effects minimisation and half-life extension of LAI-APs. Future means of improving adherence include novel administration techniques that abolish the need for injection.

CONCLUSIONS

For both, clinicians and drug developers, drug adherence remains a major target for improving treatment outcomes.

Cryo scanning transmission x-ray microscope optimized for spectrotomography

A cryo scanning transmission X-ray microscope, the cryo-STXM, has been designed and commissioned at the Canadian Light Source synchrotron. The instrument is designed to operate from 100 to 4000 eV (λ = 12.4 - 0.31 nm). Users can insert a previously frozen sample, through a load lock, and rotate it ±70° in the beam to collect tomographic data sets. The sample can be maintained for extended periods at 92 K primarily to suppress radiation damage and a pressure on the order of 10^-9 Torr to suppress sample contamination. The achieved spatial resolution (30 nm) and spectral resolution (0.1 eV) are similar to other current soft X-ray STXMs, as demonstrated by measurements on known samples and test patterns. The data acquisition efficiency is significantly more favorable for both imaging and tomography. 2D images, 3D tomograms, and 4D chemical maps of automotive hydrogen fuel cell thin sections are presented to demonstrate current performance and new capabilities, namely, cryo-spectrotomography in the soft X-ray region.

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

Obstructive Sleep Apnea is an Independent Risk Factor for Hospital Readmission

STUDY OBJECTIVES

Hospital readmissions are an important metric of quality and safety. This study seeks to characterize the relationship between readmissions and obstructive sleep apnea (OSA). A better understanding of this relationship could be utilized to develop preventative measures and reduce readmission rates.

METHODS

A retrospective review of patients discharged over a 24-month period to a Department of Defense hospital was conducted. Medical records review provided demographic data, presence of OSA and comorbid diseases, and whether readmission occurred within 30 days of discharge. Statistical analysis assessed risk factors for readmission, and multivariate analysis was performed. Next, 125 readmitted patients with OSA were randomly selected for detailed chart review and compared to a matched cohort that was not readmitted.

RESULTS

Of 22,261 unique patients discharged, 1,899 (8.5%) were readmitted. Patients with OSA had a readmission rate of 11.4% versus 7.6% for patients without OSA (P < .00001). Multivariable analysis revealed an odds ratio of 1.46 for readmission in patients with OSA (P < .0001). For the detailed chart review of 250 patients, length of hospital stay differed for the readmitted and non-readmitted groups (5.1 versus 3.6 days; P = .007). Apnea-hypopnea index (24.1 versus 27.2 events/h; P = .48) was similar between the groups. Also, inpatient (27.2% versus 26.4%) and outpatient (38.4% versus 37.6%) positive airway pressure (PAP) treatment rates were not different.

CONCLUSIONS

This study found OSA to be an independent risk factor for readmission within 30 days of discharge. PAP therapy appears to be underutilized in patients with known OSA. Additional studies are needed to define the relationship between OSA, PAP adherence, and hospital readmission.

Long-term follow-up of clozapine prescribing

OBJECTIVE

Clozapine is uniquely effective for treatment-resistant schizophrenia, and so treatment continuation is essential. We aimed to identify factors associated with an increased likelihood of clozapine discontinuation in a cohort of patients in South East London.

METHODS

We gathered demographic and treatment information such as duration of illness and antipsychotic treatment history. t-tests, chi-square tests and binary logistic regression were used to compare patients who continued and discontinued clozapine during the study and to identify predictor variables for discontinuation.

RESULTS

Out of the study population of 133 patients, 48 discontinued clozapine at least once during the study period. The majority of these (75%) stopped treatment within the first 4 years of clozapine therapy. Age, ethnicity, diagnosis and antipsychotic treatment history were not predictive of the risk of clozapine discontinuation. However, male patients were more likely to stop taking clozapine (χ² = 6.81, p = 0.009). The odds of discontinuing clozapine were 2.15 times higher for male patients. The most common reason for discontinuation was patient refusal of treatment.

CONCLUSION

We found that patients who discontinue clozapine are more likely to be male, but no other demographic variable was found to predict treatment cessation. Discontinuation usually occurred due to patient refusal of treatment.

Treatment and functional outcomes of complex tibial fractures in children and adolescents using the Ilizarov method

Aims

The aim of this study was to report the clinical, functional and radiological outcomes of children and adolescents with tibial fractures treated using the Ilizarov method.

Patients and Methods

Between 2013 and 2016 a total of 74 children with 75 tibial fractures underwent treatment at our major trauma centre using an Ilizarov frame. Demographic and clinical information from a prospective database was supplemented by routine functional and psychological assessment and a retrospective review of the notes and radiographs.

Results

Of the 75 fractures, 26 (35%) were open injuries, of which six (8%) had segmental bone loss. There were associated physeal injuries in 18 (24%), and 12 (16%) involved conversion of treatment following failure of previous management. The remaining children had a closed unstable fracture or significant soft-tissue compromise. The median follow-up was 16 months (7 to 31). All fractures united with a median duration in a frame of 3.6 months (interquartile range 3.1 to 4.6); there was no significant difference between the types of fracture and the demographics of the patients. There were no serious complications and no secondary procedures were required to achieve union. Health-related quality of life measures were available for 60 patients (80%) at a minimum of six months after removal of the frame. These indicated a good return to function (median Paediatric quality of life score, 88.0; interquartile range 70.3 to 100).

Conclusion

The Ilizarov method is a safe, effective and reliable method for the treatment of complex paediatric tibial fractures. Cite this article: Bone Joint J 2018;100-B:396-403.

Prescribing and monitoring of carbamazepine and valproate – a case note review

Aims and Method

To evaluate prescribing and monitoring of carbamazepine and valproate to patients in secondary care psychiatric units. Review of prescription cards and medical case notes.

Results

Prescribing details for 433 patients were recorded. Both carbamazepine and valproate were widely prescribed for indications not listed in their product licences. Plasma level monitoring was not frequently undertaken, particularly with valproate. Where plasma levels were measured, apparently sub-therapeutic prescribing was found to be common. For the majority of samples, it could not be established that a true trough level had been taken. Monitoring of blood function was highly variable. Overall, the quality of both prescribing and monitoring was poor.

Clinical Implications

Patients may receive sub-therapeutic treatment or experience unnecessary adverse effects. Prescribing and monitoring need to be more evidence-based in line with the ideals of clinical governance.

Prescribing of clozapine and olanzapine: dosage, polypharmacy and patient ethnicity

Aims and Method

The aim of this study was to determine the existence and extent of differences in prescribing practice for patients according to ethnic group, with two widely used atypical antipsychotics, olanzapine and clozapine. All in-patient prescription charts were screened and patients receiving olanzapine and clozapine identified. Dosage, antipsychotic co-prescription and race were recorded, along with demographic details, and evaluated using comparative statistical analysis.

Results

Overall, 1441 prescriptions were screened; 328 patients received olanzapine and 200 clozapine. Details of ethnic origin were available for 287 of those prescribed olanzapine and 188 of those prescribed clozapine. There was no significant difference between ethnic groups in age or gender, for either drug. For clozapine, dosage and extent of antipsychotic co-prescription did not differ significantly between ethnic groups; for olanzapine, there was no significant difference in daily dose between the groups, but co-prescription was significantly more common in Black (33%) than in White patients (20%; P=0.023).

Clinical Implications

Important differences in the prescription of olanzapine and clozapine between ethnic groups are uncommon, but demand further investigation. Larger studies incorporating additional baseline details such as diagnosis and body weight are called for.

Free Fluid Accumulation following Blunt Abdominal Trauma: Potential for Expansion of the Fast Protocol

Objective

To determine sites of free intra-peritoneal fluid collection following blunt abdominal trauma, with a view to refinement of the Focused Assessment by Sonography for Trauma (FAST) protocol.

Methods

This was a retrospective observational study of CT scans of subjects who had suffered blunt abdominal trauma and had free intra-peritoneal fluid detected on CT scan within 24 hours. The depth from the skin and amount of fluid at 14 abdominal sites were determined.

Results

CT scans of 105 patients were examined: 68 (64.8%) were male, mean age 36.7±18.4 years, mean injury severity score 25.4±11.6. Fluid collected most commonly at three sites: right mid-axillary line at the level of the xiphisternum (52 patients, 49.5%), lateral margin of the right rectus muscle at the level of the anterior superior iliac spine (49 patients, 46.7%) and right mid-axillary line at the level of the umbilicus (40 patients, 38.1%). Mean depth of fluid at these sites were 3.6, 3.6 and 4.2 cm, respectively.

Conclusions

Free fluid collects commonly in the area of the right iliac fossa following blunt abdominal trauma. The inclusion of this site in the FAST protocol may increase the ultrasonographic detection of free fluid in the acute trauma setting.

Mechanism of Injury and Clinical Variables in Thoracic Spine Fracture: A Case Control Study

Objective

To determine the mechanisms of injury and clinical findings significantly associated with traumatic thoracic spine (T-spine) fractures.

Methods

This was a case-control study in a tertiary adult trauma centre. Cases were patients admitted with traumatic T-spine fractures between January 1999 and August 2007, inclusive. Each case had two controls matched for gender, age and injury severity. Data were collected from patient medical records and the trauma service database. Factors potentially associated with T-spine fracture were derived from the literature, expert consensus and univariate analysis. Multivariate logistic regression was employed to determine factors significantly associated with T-spine fracture.

Results

Two hundred and sixty one cases and 512 controls were enrolled. Univariate analysis showed the mechanisms of fall from a height ≥2 meters (m) and motorbike accident ≥60 kilometers per hour were significantly associated with T-spine fracture (p<0.001). The clinical findings of thoracic back pain, tenderness, intoxication, step deformity and abnormal neurological symptoms were also significantly associated with T-spine fracture (p<0.05). Multivariate analysis indicated that falls from a height of ≥2 m and thoracic back pain were significantly and positively associated with T-spine fracture (p<0.001). However, intoxication was negatively associated with T-spine fracture.

Conclusions

Patients with T-spine injury are significantly more likely to have fallen from a height ≥2 m or to have had thoracic back pain but less likely to be intoxicated. These findings should be validated prospectively prior to development of clinical guidelines for the identification of patients who may benefit from CT screening of the thoracic spine.

Aripiprazole long-acting injection - a mirror image study of its effects on hospitalisation at one year

Second generation antipsychotic long-acting injections have a greater cost than older depots. Their cost-effectiveness has yet to be established. We conducted a non-interventional, observational, follow-up of patients prescribed aripiprazole long-acting injection in two centres using a mirror image method. Data were available for 160 patients consecutively prescribed aripiprazole long-acting injection, of whom 30 were not included in the analysis (21 forensic patients, five incomplete data and four lost to follow-up). Of the 130 patients, 66 (51%) remained on aripiprazole long-acting injection at one year. The mean number of bed days in the year following aripiprazole long-acting injection initiation reduced to 22.82/patient (standard deviation [SD]=55.07) from 30.09/patient/year (SD=30.40) over the three years before initiation ( p<0.001). The mean number of admissions fell from 0.71/patient/year (SD=0.55) to 0.45/patient/year (SD=0.93) over the same period ( p<0.001). The median number of bed days in the three years before aripiprazole long-acting injection was 21.67/year; in the year following it was zero. Outcomes were not statistically better in those who remained on aripiprazole long-acting injection at one year compared with those who discontinued. The prescribing of aripiprazole long-acting injection reduces average bed days and admissions compared with prior treatments. The reduction in bed days is of a magnitude that renders aripiprazole long-acting injection broadly cost-neutral.

Hyperprolactinaemia in first episode psychosis - A longitudinal assessment

Little is known about hyperprolactinaemia (HPL) in first episode psychosis (FEP) patients. We investigated longitudinal changes in serum prolactin in FEP, and the relationship between HPL, and antipsychotic medication and stress. Serum prolactin was recorded in FEP patients at recruitment and again, 3 and 12months later. HPL was defined as a serum prolactin level >410mIU/L (~19.3ng/ml) for males, and a serum prolactin level >510mIU/L (~24.1ng/ml) for females. From a total of 174 people with serum prolactin measurements at study recruitment, 43% (n=74) had HPL, whilst 27% (n=21/78) and 27% (n=26/95) had HPL at 3 and 12months respectively. We observed higher serum prolactin levels in females versus males (p<0.001), and in antipsychotic treated (n=68) versus antipsychotic naïve patients (p<0.0001). Prolactin levels were consistently raised in FEP patients taking risperidone, amisulpride and FGAs compared to other antipsychotics. No significant relationship was observed between perceived stress scores (β=7.13, t=0.21, df=11, p=0.0.84 95% CI -72.91-87.16), or objective life stressors (β=-21.74, t=-0.31, df=8, p=0.77 95% CI -218.57-175.09) and serum prolactin. Our study found elevated rates of HPL over the course of the first 12months of illness. We found no evidence to support the notion that stress is related to elevated serum prolactin at the onset of psychosis.

Impact of disease on the survival of three commercially fished species

Recent increases in emergent infectious diseases have raised concerns about the sustainability of some marine species. The complexity and expense of studying diseases in marine systems often dictate that conservation and management decisions are made without quantitative data on population-level impacts of disease. Mark-recapture is a powerful, underutilized, tool for calculating impacts of disease on population size and structure, even in the absence of etiological information. We applied logistic regression models to mark-recapture data to obtain estimates of disease-associated mortality rates in three commercially important marine species: snow crab (Chionoecetes opilio) in Newfoundland, Canada, that experience sporadic epizootics of bitter crab disease; striped bass (Morone saxatilis) in the Chesapeake Bay, USA, that experience chronic dermal and visceral mycobacteriosis; and American lobster (Homarus americanus) in the Southern New England stock, that experience chronic epizootic shell disease. All three diseases decreased survival of diseased hosts. Survival of diseased adult male crabs was 1% (0.003-0.022, 95% CI) that of uninfected crabs indicating nearly complete mortality of infected crabs in this life stage. Survival of moderately and severely diseased striped bass (which comprised 15% and 11% of the population, respectively) was 84% (70-100%, 95% CI), and 54% (42-68%, 95% CI) that of healthy striped bass. The disease-adjusted yearly natural mortality rate for striped bass was 0.29, nearly double the previously accepted value, which did not include disease. Survival of moderately and severely diseased lobsters was 30% (15-60%, 95% CI) that of healthy lobsters and survival of mildly diseased lobsters was 45% (27-75%, 95% CI) that of healthy lobsters. High disease mortality in ovigerous females may explain the poor recruitment and rapid declines observed in this population. Stock assessments should account for disease-related mortality when resource management options are evaluated.

Don't Label Me: A Qualitative Study of Patients' Perceptions and Experiences of Sedation During Behavioral Emergencies in the Emergency Department

OBJECTIVES

Behavioral emergencies are commonly seen in emergency departments (EDs). Acutely agitated patients can be difficult to manage and sedation may be required to decrease dangerous behavior and to ensure the safety of both the patient and the staff. While the experience of staff caring for this population has been reported, patients' experiences with their overall management remains unknown. We aimed to describe the perceptions and experiences of patients regarding the use of sedation during acute behavioral emergencies.

METHODS

Face-to-face semistructured interviews were conducted with adults aged 18 years or older, who had received parenteral sedative medication for the management of a behavioral emergency and were deemed capable to participate. The participants were asked about their experiences of receiving care in the ED during the episode and their perceptions of sedation. All interviews were transcribed verbatim and analyzed thematically.

RESULTS

Data saturation was reached after 13 interviews. Two broad themes emerged: trusting relationships and needs or wants following sedation. A trusting relationship is built through 1) confidence in care, 2) sedation as an appropriate treatment, 3) insight into own behavior, and 4) humane treatment. Four subthemes of needs or wants were identified: 1) empathy, 2) debrief, 3) addressing concerns, and 4) follow-up.

CONCLUSIONS

A trusting relationship was identified as crucial to minimize the negative impact of coercive measures used to manage behavioral emergencies. Participants expressed similar needs to patients presenting with medical problems. This study illustrates their needs for compassionate communication, adequate information about the treatment provided, and follow-up care.

Anticholinergic effect on cognition (AEC) of drugs commonly used in older people

OBJECTIVE

Use of anticholinergic drugs in older people is associated with increased risk of cognitive decline and of dementia and death.

METHOD

We identified drugs widely used in older people and attempted to classify their anticholinergic effect on cognition (AEC) according to our three-point scale which scored AEC according to in vitro anticholinergic potency, capacity to cross the blood-brain barrier and statements made in standard texts.

RESULTS

In total, 165 drugs were examined. We identified 21 drugs with an AEC score of 3, 18 with a score of 2, 21 with a score of 1 and 62 with a score of 0. Owing to insufficient information, we were unable to classify 43 drugs.

CONCLUSIONS

A large number of drugs commonly used in older people are likely to be associated with cognitive impairment. Copyright © 2016 John Wiley & Sons, Ltd.

Neuroleptic malignant syndrome following catatonia: Vigilance is the price of antipsychotic prescription

Objectives:

To describe a case of neuroleptic malignant syndrome following antipsychotic treatment of catatonia, highlighting the potentially serious complications of this rare adverse drug reaction.

Methods:

We present a case report of a patient who developed this syndrome with various sequelae.

Results:

The patient developed neuroleptic after being treated with lorazepam and olanzapine for catatonia. He subsequently developed the complications of rhabdomyolysis, acute kidney injury, pulmonary embolism, urinary retention and ileus. He received high-dose lorazepam, anticoagulation and intravenous fluids. Antipsychotic medication in the form of haloperidol was reinstated with no adverse effect, and he went on to make a full recovery.

Conclusions:

This case illustrates the potential life-threatening complications of neuroleptic malignant syndrome and the need for a low index of clinical suspicion. It also highlights the lack of evidence for treatment of catatonia, including the use of antipsychotics.

Effects of a smoking ban on clozapine plasma concentrations in a nonsecure psychiatric unit

BACKGROUND

Tobacco smoke is known to affect plasma levels of some drugs, including the antipsychotic clozapine. The effects of suddenly stopping smoking on patients who take clozapine can be severe, as plasma concentrations are expected to rapidly rise, potentially leading to toxicity. A ban on smoking at South London and the Maudsley NHS Foundation Trust (SLaM) was implemented in 2014, and this was expected to affect the plasma concentrations of clozapine for inpatients at the time. This study aimed to determine whether plasma concentrations of clozapine were affected, and additionally, in line with observations from other authors, whether levels of reported violence would also be affected.

METHODS

The smoking habits of all patients at SLaM who smoked and were prescribed clozapine were recorded both before and after the ban. The Glasgow Antipsychotic Side Effect Scale for Clozapine (GASS-C) scale was used to evaluate side-effect burden. Clozapine doses and plasma concentrations were also collected.

RESULTS

In total, 31 patients were included in this study. The mean clozapine dose before the ban was 502 mg/day, and this did not change significantly after the ban. Similarly, there were no significant changes in clozapine or norclozapine plasma concentrations, or in GASS-C scores. There was no change in the amount of tobacco patients reported smoking before or after the ban. A modest but statistically significant reduction in violent incidences was observed.

CONCLUSIONS

Our data suggest that a ban on smoking for patients taking clozapine on open wards at inpatient hospital sites had little impact on clozapine plasma concentrations, because patients continued to smoke tobacco if allowed to leave. Smoking bans may result in a reduction in violent incidences.

Long-term outcomes after severe drug overdose

OBJECTIVE

The long-term outcomes of patients with drug overdose admitted to the intensive care unit compared with those admitted to general wards have not been assessed. We aimed to compare the recurrence of overdose, mortality after hospital discharge, cause of death and quality-of-life scores (using the EQ-5D questionnaire) between the ICU patients and general ward patients.

METHODS

We performed a retrospective cohort study of 102 ICU patients with drug overdose and 102 matched general ward patients with drug overdose in a university-affiliated teaching hospital between 2009 and 2013. We undertook standardised follow-up of patients for recurrence of overdose, long-term mortality and quality-oflife assessment.

RESULTS

At 4-year follow-up, 33.3% of ICU patients had experienced further self-harm attempts, compared with 36.3% of general ward patients (P = 0.66). Ten ICU patients (10%) and five general ward patients (5%) had died. Causes of death included hanging in three patients and drug overdose in another three. On multivariate regression analysis, previous overdose attempts significantly predicted future overdoses and self-harm (odds ratio, 2.34; 95% CI, 1.27-4.30; P = 0.006). Overall, 101 patients (49.5%) were lost to follow-up and eight (3.9%) refused participation. For those remaining, EQ-5D scores were low, especially in the dimensions of anxiety/depression, usual activities and pain/discomfort.

CONCLUSIONS

ICU and general ward patients with overdose have similar, overwhelming prevalences of psychiatric disease, and similar outcome profiles. Such patients experience frequent overdoses and, despite being young, if admitted to the ICU, have a 10% 4-year mortality, with self-harm the dominant cause of death. Finally, among survivors who responded to the follow-up questionnaire, quality of life is poor.

Paliperidone palmitate: factors predicting continuation with treatment at 2 years

Our aim was to determine factors relating to continuation with treatment with paliperidone palmitate long-acting injection (PP) in a 2 year, non-interventional, observational study of the use of PP in consecutive patients treated in a secondary care environment. We followed-up 300 consecutive patients; 24 (8%) were lost to follow-up (7 deceased and 17 left the care of the trust). Overall, 107 patients of the remaining 276 who were not lost to follow-up (38.7%) completed 2 years' continuous treatment. A further 21 (7.6%) patients discontinued PP but restarted it after >2 months, 11 (4.0%) of whom were still receiving PP at 2 years. Median treatment time for PP was 465 days (95% CI 333, 583 days). Prior treatment with risperidone reduced the risk of discontinuation by 39% (RR 0.61 (95% CI -0.44, 0.86, p=0.004)); being initiated as an out-patient by 49% (RR 0.51 (95% CI 0.36, 0.73 p=0.001)). Risk of discontinuation was increased by 63% when the reason for prescribing PP was poor tolerability of prior treatment (RR 1.63 (95% CI 1.05, 2.51 p=0.028)). The rate of continuation with PP at 2 years was higher than that seen with other long acting depot formulations. Likelihood of continuation can be vastly improved by targeting PP for those most likely to benefit.

Factors associated with changes in hospitalisation in patients prescribed clozapine

OBJECTIVE

The objective of this study was to examine whether delays in clozapine treatment affect outcomes once clozapine is started and identify factors that affect these outcomes.

METHOD

Patients starting clozapine in a four year period at South London and the Maudsley NHS Foundation Trust were included. Clinical details were gathered from clinical notes. Primary outcome was net change in inpatient admissions comparing the periods before and after clozapine was started.

RESULTS

There was no significant association between the length of clozapine delay (mean clozapine delay = 3.93 years) and number or length of inpatient admissions once clozapine had been started (mean net change in days of admission = 16.74 days), F value = 0.901, p = 0.345. Clozapine reduced the total number of bed days per year, but only if treatment was continued - stopping resulted in inpatient admissions returning to pre-clozapine levels. Younger patients had a greater reduction in bed days when taking clozapine (p = 0.027).

CONCLUSION

Clozapine reduces the number of inpatient days, regardless of the chronicity of the illness at the time clozapine was started. Continued compliance with clozapine is necessary to maintain this benefit. Reduction in bed days is greater in younger patients, suggesting early initiation of clozapine may be beneficial.

Conundrums in neurology: diagnosing serotonin syndrome - a meta-analysis of cases

Background

Serotonin syndrome is a toxic state, caused by serotonin (5HT) excess in the central nervous system. Serotonin syndrome’s main feature is neuro-muscular hyperexcitability, which in many cases is mild but in some cases can become life-threatening. The diagnosis of serotonin syndrome remains challenging since it can only be made on clinical grounds. Three diagnostic criteria systems, Sternbach, Radomski and Hunter classifications, are available. Here we test the validity of four assumptions that have become widely accepted: (1) The Hunter classification performs clinically better than the Sternbach and Radomski criteria; (2) in contrast to neuroleptic malignant syndrome, the onset of serotonin syndrome is usually rapid; (3) hyperthermia is a hallmark of severe serotonin syndrome; and (4) serotonin syndrome can readily be distinguished from neuroleptic malignant syndrome on clinical grounds and on the basis of medication history.

Methods

Systematic review and meta-analysis of all cases of serotonin syndrome and toxicity published between 2004 and 2014, using PubMed and Web of Science.

Results

Two of the four assumptions (1 and 2) are based on only one published study each and have not been independently validated. There is little agreement between current criteria systems for the diagnosis of serotonin syndrome. Although frequently thought to be the gold standard for the diagnosis of the serotonin syndrome, the Hunter criteria did not perform better than the Sternbach and Radomski criteria. Not all cases seem to be of rapid onset and only relatively few cases may present with hyperthermia. The 0 differential diagnosis between serotonin syndrome and neuroleptic malignant syndrome is not always clear-cut.

Conclusions

Our findings challenge four commonly made assumptions about serotonin syndrome. We propose our meta-analysis of cases (MAC) method as a new way to systematically pool and interpret anecdotal but important clinical information concerning uncommon or emergent phenomena that cannot be captured in any other way but through case reports.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0616-1) contains supplementary material, which is available to authorized users.

Factors predicting use of laxatives in outpatients stabilized on clozapine

Constipation is a common and sometimes fatal side effect of clozapine treatment. In this study, we aimed to identify factors associated with clozapine-induced constipation. Data on 202 outpatients stabilized on clozapine treatment were collected. Of these, 71 patients (35%) had a current prescription for laxatives (a proxy for the presence of constipation). Mean clozapine dose was 400.4 mg/day in those prescribed laxatives and 390.1 mg/day in those not prescribed laxatives (p = 0.67), while mean clozapine plasma concentration was 0.53 mg/l and 0.49 mg/l, respectively (p = 0.29). Patients using laxatives had on average 29% higher norclozapine concentrations (mean = 0.34 mg/l) than those who did not use laxatives (mean = 0.27 mg/l; p = 0.046). Laxative use was more common in female patients (49.1%) than male patients (29.1%; p < 0.01). Prescribers should be vigilant for constipation at any dose or plasma concentration of clozapine and should be mindful that male patients may be undertreated. Norclozapine concentrations may predict clozapine-induced constipation.

The impact of command signal power distribution, processing delays, and speed scaling on neurally-controlled devices

OBJECTIVE

Decoding algorithms for brain-machine interfacing (BMI) are typically only optimized to reduce the magnitude of decoding errors. Our goal was to systematically quantify how four characteristics of BMI command signals impact closed-loop performance: (1) error magnitude, (2) distribution of different frequency components in the decoding errors, (3) processing delays, and (4) command gain.

APPROACH

To systematically evaluate these different command features and their interactions, we used a closed-loop BMI simulator where human subjects used their own wrist movements to command the motion of a cursor to targets on a computer screen. Random noise with three different power distributions and four different relative magnitudes was added to the ongoing cursor motion in real time to simulate imperfect decoding. These error characteristics were tested with four different visual feedback delays and two velocity gains.

MAIN RESULTS

Participants had significantly more trouble correcting for errors with a larger proportion of low-frequency, slow-time-varying components than they did with jittery, higher-frequency errors, even when the error magnitudes were equivalent. When errors were present, a movement delay often increased the time needed to complete the movement by an order of magnitude more than the delay itself. Scaling down the overall speed of the velocity command can actually speed up target acquisition time when low-frequency errors and delays are present.

SIGNIFICANCE

This study is the first to systematically evaluate how the combination of these four key command signal features (including the relatively-unexplored error power distribution) and their interactions impact closed-loop performance independent of any specific decoding method. The equations we derive relating closed-loop movement performance to these command characteristics can provide guidance on how best to balance these different factors when designing BMI systems. The equations reported here also provide an efficient way to compare a diverse range of decoding options offline.