Possible utility of neutrophil/lymphocyte ratio as a predictor of suicidal risk in mood disorders

Introduction

Correlations between neutrophil/lymphocyte, platelet/lymphocyte, and monocyte/lymphocyte ratios (NLR, PLR, and MLR, respectively) and psychopathological and clinical variables in the context of mood disorders are increasingly emerging in international scientific literature, being the former one of the most studied. The estimation of suicidal risk associated to affective disorders could benefit from such rapidly and easily available biomarker of inflammation, if significant in this regard.

Objectives

The present review would like to focus on any existing correlations between NLR and suicidal risk in patients with mood disorders.

Methods

We sourced articles on the topic found in major scientific literature databases, combining the keywords “neutrophil/lymphocyte ratio”, “NLR”, “mood disorders”, “major depressive disorder”, “bipolar disorder” and “suicide risk”.

Results

There are congruent findings of significantly higher NLR values in depressed patients attempting suicide than in depressed patients with no suicidal behaviors or healthy controls. In addition, violent means appear typical in this subgroup of depressed suicidal patients, suggesting that patients with higher levels of NLR are at risk of attempting suicide and to be successful in self-harming. Similar results have been found in patients with bipolar disorder, showing a positive correlation between NRL and suicide risk, evaluated by the Suicide Behaviors Questionnaire-Revised (SBQ-R). Moreover, in patients with a positive family history for suicide attempts, NRL was found to be a significant positive predictor of suicide risk.

Conclusions

These findings, although limited, support the notion that NLR might be a useful marker for suicide vulnerability in both BD and MDD patients.

Disclosure

No significant relationships.

Focus on neuroenhancement: a systematic review and its ethical implications

Introduction

Pharmacological and cognitive neuroenhancement refer to the non-medical use of prescription drugs, alcohol, illegal drugs, or the so-called soft enhancers, to enhance cognition, mood, work or school performance, or to promote pro-social behaviour. Literature on the topic is meagre, and available data only partially enlightens their use.

Objectives

The aim of this paper is to review and comment on the available literature on pharmacological neuroenhancement and, secondary, on emotional enhancement.

Methods

A systematic review was conducted according to the PRISMA guidelines. Pubmed, Scopus, Embase, PsychInfo and Google Scholar databases were accessed to select English language articles, published from 1980 to April 2020. 11746 papers were initially selected and 123 papers were finally included.

Results

Available literature indicates a widespread and increasing use of different kinds of substances, drugs and food supplements mainly with neuroenhancing purposes, especially amongst specific populations of young healthy subjects. The evidence regarding their efficacy is controversial. Further, a limited or no awareness regarding the possible consequences of their abuse/misuse emerges amongst users.

Conclusions

Despite the limited evidence that some substances may improve cognitive functions in healthy subjects and neglecting their detrimental side effects and potential risk of misuse, abuse and addiction, there is an increasing worldwide use of the so-called neuroenhancers, especially in some categories of individuals, such as university students. Further studies are needed to collect reliable data on the effects of neuroenhancers in healthy subjects. Neuroenhancement puts into question the concept of authenticity, so that the problem requires to be analyzed within a complex ethical conceptual frame.

Disclosure

No significant relationships.

Subthreshold Autism Spectrum in a Patient with Anorexia Nervosa and Behçet's Syndrome

Recently, increasing research stressed the presence of subthreshold autistic traits in patients with other psychiatric conditions. In this framework, a significant relationship between anorexia nervosa (AN) and the autism spectrum has been frequently reported, in particular among female samples, to the point that AN has been hypothesized to be a female phenotype of autism spectrum disorder (ASD). On the other hand, among subjects with ASD has been reported a higher prevalence of immune diseases and altered immune functions. While these reports seem to support an association between neurodevelopmental and immune system alterations in ASD, the relationship between the immune system and the broader autism spectrum, including its subthreshold manifestations, remains poorly investigated. In this report, we described the presence of autistic traits in a male inpatient with AN and separation anxiety disorder, who also show a diagnosis of Behçet's syndrome (BS). This case seems to further stress the association between AN and the autism spectrum, which may not be limited to the female gender. Moreover, it further suggests a deeper link between neurodevelopmental and immune system alterations. Implications are discussed in light of the more recent neurobiological and psychopathological hypothesis about the autism spectrum.

Safety of cardioversion in atrial fibrillation lasting less than 48 h without post-procedural anticoagulation in patients at low cardioembolic risk

Currently, there is no unified consensus on short-term anticoagulation after cardioversion of atrial fibrillation lasting less than 48 h in low-cardioembolic-risk patients. The aim of this study is to evaluate the rate of transient ischemic attacks, stroke and death in this subset of patients after cardioversion without post-procedural anticoagulation. In a prospective observational study, patients with recent-onset AF undergoing cardioversion attempts in the Emergency Department were evaluated over the past 3 years. Inclusion criteria were conversion to sinus rhythm, low thromboembolic risk defined by a CHA2DS2VASc score of 0-1 points for males (0-2 points for females aged over 65 years), and hospital discharge without anticoagulant treatment. Patients with severe valvular heart disease, underlying systemic causes of AF, and those discharged with anticoagulant therapy were excluded. The main outcomes measured were TIA, stroke and death at thirty days' follow-up after discharge. During the study period, 218 successful cardioversions, obtained both electrically and pharmacologically, were performed on 157 patients. One hundred and eleven patients were males (71%), the mean age was 55.2 years (±standard deviation 10.7), 99 patients (63%) reported a CHA2DS2VASc score of 0, and the remaining 58 (37%) had a risk profile of 1 point. Of these, latter 8 were females (5%) older than 65 years (risk score 2 points). At the thirty days outcome, none of the 150 enrolled patients who completed a follow-up visit has reported TIA or stroke, nor died, in the overall 211 successful cardioversions evaluated. In our study, the rate of thromboembolic events after cardioversion of recent-onset AF of less than 48 h duration, in patients with a 0-1 CHA2DS2VASc risk profile (females 0-2), appeared to be extremely low even in absence of post-procedural anticoagulation. These findings seem to confirm data from previous studies, and suggest that routine post-procedural short-term anticoagulation may be considered as an overtreatment in this very low-risk subset of patients.

Unconventional side effects of antidepressants: Focus on emotional blunting

Objectives

The aim of this study was to investigate the unconventional side-effects of selective serotonin reuptake inhibitors (SSRIs) and tricyclics (TCAs) antidepressants during long-term treatment of depression, with a special focus on emotional blunting and, in particular, on the possible changes of some features of loving relationships.

Methods

Two hundred outpatients (130 women and 70 men, mean age ± SD: 43.4 ± 11.1 years) were enrolled. They were suffering from mild or moderate depression, according to DSM–5 criteria, treated with one antidepressant for at least six months and involved in a long-term loving relationship. A specifically designed test, the so-called “sex, attachment, love” (SALT) questionnaire was built to assess the possible changes of the loving relationship.

Results

The results showed differences between the two genders, in particular women taking TCAs reported more sexual side effects than men, whereas men taking SSRIs complained a reduction of the feelings of love and attachment towards the partner.

Conclusions

Antidepressants seem to have a dimorphic effect on some elements of loving relationships, however these results need to be further explored.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Impulsivity and pathological gambling: An Italian study

Introduction

Pathological gambling (PG) is a behavioral addictive disorder characterized by persistent and problematic gambling behaviors, in presence of impairment of self-regulation and impulsivity. Impulsivity is widely supported by literature in developing and maintaining addictive behaviors and PG.

Aim(s)

The aim of this study is to compare PG to impulsivity in a group of Italian outpatients, in order to further explore their appealing relation and to sensitize local public institutions about this problem that is of growing concern amongst our population.

Methods

Fifty outpatients were recruited at the psychiatric outpatient ward of the University of Pisa. All of them had a diagnosis of PG, assessed throughout the structured clinical interview for DSM-5 (SCID-5). The sample was compared with a similar group of healthy control subjects. South Oaks Gambling Screen (SOGS) scale and Barrat Impulsivity Scale (BIS-11) questionnaires were used to assess respectively the severity of PG and impulsivity traits of personality.

Results

PG patients reported significantly higher total score in BIS-11 than control subjects. In particular, the “motor impulsivity” and “cognitive complexity” scores were significantly higher in PG patients, as well as “motor” and “non-planning” impulsivity subscale scores. A positive and significant correlation was found between BIS-11 and SOGS total scores.

Conclusions

These results corroborate the existence of the widely described association between impulsivity and PG. Also they support the notion that impulsivity may represent a core element of PG and, perhaps, to a typical personality trait, that may be particularly related to the development of addictive and impulsive behaviors.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Ionizing radiation: brain effects and related neuropsychiatric manifestations

Recently, an increasing interest has been directed towards the investigation of brain effects of ionizing radiation (IR), as it is now evident that, depending on the doses, the damages character and severity, as well as clinical man ifestations are different. They are generally considered to be the result of a blending of atherosclerotic, cardiovas cular, cerebrovascular and neurodegenerative processes. Further, an ongoing debate has been opened on the pos sible brain abnormalities following medical radiation from X ray in interventional radiology and nuclear medicine procedures that would involve both patients and medical workers. The aim of the present paper is to summarize literature data on brain effects of IR exposure, with a special focus on those gathered by some of the authors after the Chornobyl nuclear plant disaster, and how they can be related to the pathophysiology of different neuropsy chiatric disorders.

Severe symptomatic bradycardia after a dinner of spicy oleander soup

Introduction: Cardiac glycosides similar to digoxin are produced by different plants in nature. Nerium oleander, commonly grown as an ornamental shrub, can be found worldwide in temperate countries. Intentional or accidental ingestion of any part of the plant can lead to clinically relevant intoxication. Case report: A 63 year old woman came to the emergency department with acute dyspeptic symptoms after eating vegetable soup flavored with unfamiliar flowers she have collected herself. However, the ECG showed abnormalities that raised suspicions for an overdose of digoxin-like cardiac glycosides. The patient was not on treatment with digoxin and a careful anamnesis revealed that she had eaten oleander leaves. Digoxin specific Fab antibody fragments were administered for marked bradycardia that was not responding to atropine administration, after counseling with the reference toxicology center. The patient was also treated with activated charcoal and magnesium sulphate, intravenous fluids and pantoprazole. Four days later she was discharged as asymptomatic, with normal sinus rhythm. Conclusion: Emergency physicians should be aware of this type of poisoning, especially in cases with typical ECG alterations in patients not treated with digoxin and medical history of plants ingestion. Cardio-active glycosides are present in different plants, often used inappropriately, with potential toxic effects and harmful drug interactions.

Prevention of Edema in Long Flights with Pycnogenol®

The aim of this study was to evaluate the prevention of edema during long-haul flights with an oral, anti-edema and antithrombotic agent (Pycnogenol®, Horphag, Research Management SA, Geneva, Switzerland) in asymptomatic subjects. The assessment of edema was performed by evaluating an analogue scale, the rate of ankle swelling by strain-gauge derived rate of ankle swelling (RAS), and by assessing the ankle circumference variation. The study included 211 subjects; 169 completed the study (88 in the control group and 81 in the Pycnogenol® group). There were no important differences between the two groups (comparable for age, gender, weight, body mass index, and pattern distribution). The edema score, the RAS, and the circumference at inclusion were also comparable. After the flight in those treated with Pycnogenol®, the edema score was increased only by 17.9% (vs. an increase of 58.3% in the control group) (p<0.05). The RAS, evaluated in 22 subjects in the Pycnogenol® group (age 44.5; SD 8) and in 23 in the control group (age 45; SD 9) was increased on average by 91% in the control group and 36% in the Pycnogenol® group (p<0.05). The variation on circumference at the ankle was 6% in the Pycnogenol® group (11% in the control group; p<0.05). These results indicate a positive effect of Pycnogenol® on edema during long flights when considering subjective and objective data. No unwanted effects were observed.

Alpha-1-thymosin and transcatheter arterial chemoembolization in hepatocellular carcinoma patients: a preliminary experience

BACKGROUND/AIMS

To evaluate the tolerability and therapeutic potential of the immunostimulating adjuvant alpha-1-thymosin in patients with hepatocellular carcinoma.

METHODOLOGY

Twelve patients with hepatocellular carcinoma were treated with alpha-1-thymosin (900 micrograms/m2 subcutaneously twice per week for 6 months) and transcatheter arterial chemoembolization and compared to a historical control group (matched for gender, age, Okuda staging, Child's score, alpha-fetoprotein serum levels and viral infection) treated with transcatheter arterial chemoembolization alone.

RESULTS

No severe side effects were recorded in the 2 treatment groups. The combination of alpha-1-thymosin plus transcatheter arterial chemoembolization resulted in a longer survival that reached statistical significance 7 months after the end of treatment (p < 0.05). Patients receiving combined treatment demonstrated a significant increase in peripheral blood mononuclear cells expressing CD3 (p < 0.05) and CD8 (p < 0.025) 3 months after beginning treatment. They also had a significant increase (p < 0.05) in CD16+ and CD56+ cells after 1 month, and a slight reduction in mononuclear cells expressing CD25, a marker for cell activation. No alterations in the response to phytohemagglutinin stimulation were seen during the alpha-1-thymosin treatment.

CONCLUSIONS

The absence of toxicity and the favourable effects observed in this open study call for a double blind control study to confirm the efficacy of the combined treatment.

Chemoembolization versus chemotherapy in elderly patients with unresectable hepatocellular carcinoma and contrast uptake as prognostic factor

BACKGROUND

Age is considered one of the important contraindications to surgery for hepatocellular carcinoma (HCC) in cirrhosis patients. We therefore evaluated the safety and prevalence of side effects in endoarterial therapy (EAT) in subjects aged over 65 years compared with younger treated patients.

METHODS

Thirty-eight patients with HCC aged 65 years and over underwent transcatheter arterial chemoembolization (TACE) (n = 28) or intraarterial chemotherapy (IAC) (n = 10). The survival rate was calculated using Kaplan-Meier's method with respect to a control group consisting of younger treated subjects (44 TACE; 21 IAC) comparable for stage of HCC and severity of the underlying cirrhosis.

RESULTS

The comparison between the two groups regarding side effects, procedure-related death, and survival did not show any difference considering the whole EAT procedure. TACE in elderly subjects reached a statistically lower outcome with respect to younger patients (p < .025) but remained statistically superior in survival versus both older and younger patients treated with IAC (p < .05, respectively). Stratifying the patients following the degree of Lipiodol uptake of tumor mass in the three groups (Group I, > 75%; Group II, 50-75%; Group III, < 50%), in the young subjects a higher probability of survival was strictly correlated to a degree of uptake over 75%, while in the elderly patients an impregnation over 50% was sufficient to obtain a satisfactory survival curve.

CONCLUSIONS

EAT is a reliable and safe therapeutic option for the geriatric patient with HCC, with TACE showing a better efficacy than IAC, requiring a lesser degree of Lipiodol uptake to achieve an improvement of outcome.

Efficacy of transarterial targeted treatments on survival of patients with hepatocellular carcinoma. An Italian experience

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) are not suitable for surgical therapy. Systemic chemotherapy, immunotherapy, and hormonotherapy have not had convincingly acceptable results. Therefore, transarterial catheter-targeted therapies such as intraarterial chemotherapy (IAC), possibly followed by transcatheter arterial chemoembolization (TACE), have been proposed.

METHODS

A survival analysis curve was drawn using the Kaplan-Meier method for 164 patients, 100 with HCC who underwent TACE (69) or IAC (31), and a matched historic group of 64 who did not receive specific antineoplastic treatment.

RESULTS

A significantly more favorable survival was observed for TACE-treated patients compared with IAC-treated patients (P < 0.001); TACE- and IAC-treated patients had a statistically superior survival than that of untreated patients (P < 0.001 and P < 0.025, respectively). This difference was still significant (P < 0.001) when the patients were subdivided into Classes A and B and Stages I and II following Child's and Okuda's criteria. The TACE- and IAC-treated groups had a good relationship between technical efficacy of therapy and survival. Stratifying the patients according to the degree of iodized oil (Lipiodol Ultrafluid, Guerbet, Aulnay-Sous-Bois, France) uptake in the three groups with Group 1 having an uptake greater than 75% of tumor mass, Group 2 having an uptake of 50%-75%, and Group 3 having an uptake less than 50%, survival at 6, 12, 24, 36, and 48 months was calculated as 94%, 88%, 67%, 53%, and 30%, respectively, for Group 1; 86%, 68%, 13%, 13%, and 0% for Group 2, and 43%, 23%, 6%, 6%, and 0% for Group 3 (Group 1 vs. Group 2: P < 0.001; Group 1 vs. Group 3: P < 0.001; Group 2 vs. Group 3: P < 0.001, respectively). The most important side effects after the intraarterial procedure were fever (46.2%), abdominal pain (36.6%), chemical cholecystitis (8%), and pancreatitis (1.7%). Death strictly related to treatment occurred in two patients; one had massive bleeding due to ruptured esophageal varices, and the other had a subphrenic abscess of a superficial HCC of the VIII segment.

CONCLUSIONS

Transcatheter arterial chemoembolization and IAC were effective and relatively safe, and the authors believe that they have a primary role in treating patients with unresectable HCC larger than 5 cm; iodized oil uptake can be considered a suitable prognostic marker.

Efficacy of transarterial targeted treatments on survival of patients with hepatocellular carcinoma. An Italian experience

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) are not suitable for surgical therapy. Systemic chemotherapy, immunotherapy, and hormonotherapy have not had convincingly acceptable results. Therefore, transarterial catheter-targeted therapies such as intraarterial chemotherapy (IAC), possibly followed by transcatheter arterial chemoembolization (TACE), have been proposed.

METHODS

A survival analysis curve was drawn using the Kaplan-Meier method for 164 patients, 100 with HCC who underwent TACE (69) or IAC (31), and a matched historic group of 64 who did not receive specific antineoplastic treatment.

RESULTS

A significantly more favorable survival was observed for TACE-treated patients compared with IAC-treated patients (P < 0.001); TACE- and IAC-treated patients had a statistically superior survival than that of untreated patients (P < 0.001 and P < 0.025, respectively). This difference was still significant (P < 0.001) when the patients were subdivided into Classes A and B and Stages I and II following Child's and Okuda's criteria. The TACE- and IAC-treated groups had a good relationship between technical efficacy of therapy and survival. Stratifying the patients according to the degree of iodized oil (Lipiodol Ultrafluid, Guerbet, Aulnay-Sous-Bois, France) uptake in the three groups with Group 1 having an uptake greater than 75% of tumor mass, Group 2 having an uptake of 50%-75%, and Group 3 having an uptake less than 50%, survival at 6, 12, 24, 36, and 48 months was calculated as 94%, 88%, 67%, 53%, and 30%, respectively, for Group 1; 86%, 68%, 13%, 13%, and 0% for Group 2, and 43%, 23%, 6%, 6%, and 0% for Group 3 (Group 1 vs. Group 2: P < 0.001; Group 1 vs. Group 3: P < 0.001; Group 2 vs. Group 3: P < 0.001, respectively). The most important side effects after the intraarterial procedure were fever (46.2%), abdominal pain (36.6%), chemical cholecystitis (8%), and pancreatitis (1.7%). Death strictly related to treatment occurred in two patients; one had massive bleeding due to ruptured esophageal varices, and the other had a subphrenic abscess of a superficial HCC of the VIII segment.

CONCLUSIONS

Transcatheter arterial chemoembolization and IAC were effective and relatively safe, and the authors believe that they have a primary role in treating patients with unresectable HCC larger than 5 cm; iodized oil uptake can be considered a suitable prognostic marker.