A Plasmodium falciparum genetic cross reveals the contributions of pfcrt and plasmepsin II/III to piperaquine drug resistance

Piperaquine (PPQ) is widely used in combination with dihydroartemisinin (DHA) as a first-line treatment against malaria parasites. Multiple genetic drivers of PPQ resistance have been reported, including mutations in the Plasmodium falciparum chloroquine resistance transporter (pfcrt) and increased copies of plasmepsin II/III (pm2/3). We generated a cross between a Cambodia-derived multi-drug resistant KEL1/PLA1 lineage isolate (KH004) and a drug susceptible parasite isolated in Malawi (Mal31). Mal31 harbors a wild-type (3D7-like) pfcrt allele and a single copy of pm2/3, while KH004 has a chloroquine-resistant (Dd2-like) pfcrt allele with an additional G367C substitution and four copies of pm2/3. We recovered 104 unique recombinant progeny and examined a targeted set of progeny representing all possible combinations of variants at pfcrt and pm2/3 for detailed analysis of competitive fitness and a range of PPQ susceptibility phenotypes, including PPQ survival assay (PSA), area under the dose-response curve (AUC), and a limited point IC50 (LP-IC50). We find that inheritance of the KH004 pfcrt allele is required for PPQ resistance, whereas copy number variation in pm2/3 further enhances resistance but does not confer resistance in the absence of PPQ-R-associated mutations in pfcrt. Deeper investigation of genotype-phenotype relationships demonstrates that progeny clones from experimental crosses can be used to understand the relative contributions of pfcrt, pm2/3, and parasite genetic background, to a range of PPQ-related traits and confirm the critical role of the PfCRT G367C substitution in PPQ resistance.

Replication of a neuroimaging biomarker for striatal dysfunction in psychosis

To bring biomarkers closer to clinical application, they should be generalizable, reliable, and maintain performance within the constraints of routine clinical conditions. The functional striatal abnormalities (FSA), is among the most advanced neuroimaging biomarkers in schizophrenia, trained to discriminate diagnosis, with post-hoc analyses indicating prognostic properties. Here, we attempt to replicate its diagnostic capabilities measured by the area under the curve (AUC) in receiver operator characteristic curves discriminating individuals with psychosis (n=101) from healthy controls (n=51) in the Human Connectome Project for Early Psychosis. We also measured the test-retest (run 1 vs 2) and phase encoding direction (i.e., AP vs PA) reliability with intraclass correlation coefficients (ICC). Additionally, we measured effects of scan length on classification accuracy (i.e., AUCs) and reliability (i.e., ICCs). Finally, we tested the prognostic capability of the FSA by the correlation between baseline scores and symptom improvement over 12 weeks of antipsychotic treatment in a separate cohort (n=97). Similar analyses were conducted for the Yeo networks intrinsic connectivity as a reference. The FSA had good/excellent diagnostic discrimination (AUC=75.4%, 95%CI=67.0%-83.3%; in non-affective psychosis AUC=80.5%, 95%CI=72.1-88.0%, and in affective psychosis AUC=58.7%, 95%CI=44.2-72.0%). Test-retest reliability ranged between ICC=0.48 (95%CI=0.35-0.59) and ICC=0.22 (95%CI=0.06-0.36), which was comparable to that of networks intrinsic connectivity. Phase encoding direction reliability for the FSA was ICC=0.51 (95%CI=0.42-0.59), generally lower than for networks intrinsic connectivity. By increasing scan length from 2 to 10 minutes, diagnostic classification of the FSA increased from AUC=71.7% (95%CI=63.1%-80.3%) to 75.4% (95%CI=67.0%-83.3%) and phase encoding direction reliability from ICC=0.29 (95%CI=0.14-0.43) to ICC=0.51 (95%CI=0.42-0.59). FSA scores did not correlate with symptom improvement. These results reassure that the FSA is a generalizable diagnostic - but not prognostic - biomarker. Given the replicable results of the FSA as a diagnostic biomarker trained on case-control datasets, next the development of prognostic biomarkers should be on treatment-response data.

Replication of a neuroimaging biomarker for striatal dysfunction in psychosis

To bring biomarkers closer to clinical application, they should be generalizable, reliable, and maintain performance within the constraints of routine clinical conditions. The functional striatal abnormalities (FSA), is among the most advanced neuroimaging biomarkers in schizophrenia, trained to discriminate diagnosis, with post-hoc analyses indicating prognostic properties. Here, we attempt to replicate its diagnostic capabilities measured by the area under the curve (AUC) in receiver operator characteristic curves discriminating individuals with psychosis (n=101) from healthy controls (n=51) in the Human Connectome Project for Early Psychosis. We also measured the test-retest (run 1 vs 2) and phase encoding direction (i.e., AP vs PA) reliability with intraclass correlation coefficients (ICC). Additionally, we measured effects of scan length on classification accuracy (i.e., AUCs) and reliability (i.e., ICCs). Finally, we tested the prognostic capability of the FSA by the correlation between baseline scores and symptom improvement over 12 weeks of antipsychotic treatment in a separate cohort (n=97). Similar analyses were conducted for the Yeo networks intrinsic connectivity as a reference. The FSA had good/excellent diagnostic discrimination (AUC=75.4%, 95%CI=67.0%-83.3%; in non-affective psychosis AUC=80.5%, 95%CI=72.1-88.0%, and in affective psychosis AUC=58.7%, 95%CI=44.2-72.0%). Test-retest reliability ranged between ICC=0.48 (95%CI=0.35-0.59) and ICC=0.22 (95%CI=0.06-0.36), which was comparable to that of networks intrinsic connectivity. Phase encoding direction reliability for the FSA was ICC=0.51 (95%CI=0.42-0.59), generally lower than for networks intrinsic connectivity. By increasing scan length from 2 to 10 minutes, diagnostic classification of the FSA increased from AUC=71.7% (95%CI=63.1%-80.3%) to 75.4% (95%CI=67.0%-83.3%) and phase encoding direction reliability from ICC=0.29 (95%CI=0.14-0.43) to ICC=0.51 (95%CI=0.42-0.59). FSA scores did not correlate with symptom improvement. These results reassure that the FSA is a generalizable diagnostic - but not prognostic - biomarker. Given the replicable results of the FSA as a diagnostic biomarker trained on case-control datasets, next the development of prognostic biomarkers should be on treatment-response data.

Sentinel Lymph Node Biopsy for Extremity and Truncal Soft Tissue Sarcomas: A Systematic Review of the Literature

BACKGROUND

Regional lymph node metastasis (RLNM) occurs infrequently in patients with soft tissue sarcoma (STS), although certain STS subtypes have a higher propensity for RLNM. The identification of RLNM has significant implications for staging and prognosis; however, the precise impact of node-positive disease on patient survival remains a topic of controversy. Although the benefits of sentinel lymph node biopsy (SLNB) are well documented in patients with melanoma and breast cancer, whether this procedure offers a benefit in STS is controversial.

METHODS

A systematic literature search was performed and articles reviewed to determine if SLNB in patients with extremity/truncal STS impacts disease-free or overall survival.

RESULTS

Six studies were included. Rates of sentinel lymph node positivity were heterogeneous (range 4.3-50%). The impact of SLNB on patient outcomes remains unclear. The overall quality of available evidence was low, as assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system.

CONCLUSIONS

The literature addressing the impact of nodal basin evaluation on the staging and management of patients with extremity/truncal STS is confounded by heterogeneous patient cohorts and clinical practices. Multicenter prospective studies are warranted to determine the true incidence of RLNM and whether SLNB could benefit patients with clinically occult RLNM at diagnosis.

Do Clinicians Need to Rethink Antipsychotic Maintenance Treatment?

Schizophrenia remains a challenging illness to treat despite considerable progress. The heterogeneity of symptoms and variability in course, outcome, and treatment response lead to considerable uncertainties in treatment guidelines. One of the most challenging issues is how to determine the need for and duration of the maintenance treatment that is intended to reduce the risk of exacerbation, relapse, and hospitalization. It is clear that in large populations, antipsychotic medication is very effective in reducing those risks, however, there is likely a subpopulation of patients with diminished risk for such outcomes even when medication is discontinued. Although attempts have been made to utilize “intermittent” or “targeted” treatment, those randomized controlled trials that have been conducted show a statistically significant advantage for continuous treatment. At the same time, many patients continue to receive higher than necessary doses of antipsychotic medication and practice needs to be reevaluated in terms of dosage requirements. The challenge remains that there are no good biomarkers or predictors of who is at risk and, therefore, dosage reduction is only titrated against exacerbation or relapse. We need to proactively reconsider who requires maintenance treatment by establishing predictive biomarkers (clinical or biological) that can help us to have a more personalized approach.

Disclosure

Consultant to or receives honoraria: Alkermes, Allergan, Dainippon Sumitomo, H. Lundbeck, Indivior, Intracellular Therapies, Janssen Pharmaceutical, Johnson & Johnson, LB Pharmaceuticals, Merck, Minerva, Neurocrine, Novartis Pharmaceuticals,

Co-occurrence of clozapine-related DRESS syndrome core clinical manifestations: results of a systematic review

Introduction

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome refers to a cluster of clinical symptoms/signs related to drug hypersensitivity. The main clinical features include fever, skin rash, eosinophilia, enlarged lymph nodes, atypical lymphocytosis, and involvement of at least one internal organ. Clozapine-related DRESS syndrome has been rarely reported, but this may be due to a different clinical presentation pattern compared to DRESS for other culprit drugs.

Objectives

We aimed to assess clusters of main clinical features of clozapine-related DRESS.

Methods

We ran a network analysis for clinical manifestations in the pooled sample of all previous published cases of clozapine-related DRESS.

Results

We observed a triad of core symptoms (i.e., organ implication, fever, and eosinophilia) among DRESS criteria co-occurring in 59.3% (n=16) of 27 patients. The organs most likely to be involved in clozapine-related DRESS included lungs, liver, heart, and kidneys. Fever was also present in almost all cases (n=25 patients), while eosinophilia was observed in two thirds of the sample (n=18 patients).

Conclusions

Regarding clinical manifestations clozapine-related DRESS may differ from DRESS for other culprit drugs as skin reaction is not very typical; thus, clinicians need to consider DRESS as a potential diagnosis even in absence of a skin reaction. When managing clozapine-treated patients with the core triad of organ implication, fever, and eosinophilia clinicians should consider guidelines for DRESS treatment.

Disclosure

No significant relationships.

Assessing Smoke-Free Housing Implementation Approaches to Inform Best Practices: A National Survey of Early-Adopting Public Housing Authorities

Secondhand smoke (SHS) exposure causes chronic illness and occurs at a higher prevalence in low-income communities than the general public. In 2018, the U.S. Department of Housing and Urban Development (HUD) instituted a smoke-free housing rule for Public Housing Authorities (PHAs) to address persistent health inequities. However, the success of smoke-free housing requires evidence to inform effective implementation approaches. A mixed-methods, cross-sectional survey was conducted in a national sample of PHAs. Questions focused on housing officials’ use of specific implementation strategies. Adjusted odds ratios were used to assess associations between implementation approaches and variations among PHAs (i.e., region, size, or recency of policy adoption). Qualitative analyses were conducted to assess the perceived effectiveness of implementation strategies. Resident engagement, staff training, and smoking cessation support were the most frequently used implementation strategies. Engagement with local stakeholders was cited less frequently. Enforcement actions were limited with no violations referred to housing court. Support for policy adherence was identified as a sixth implementation strategy. While most PHAs used at least some evidence-informed implementation strategies, a lack of a systematic approach may limit overall effectiveness. Further research is required to resolve implementation barriers experienced disproportionately by a subset of PHAs, and to inform a best practice implementation framework that meets the needs of a heterogeneous population.

Physical and mental health impact of COVID-19 on children, adolescents, and their families: The Collaborative Outcomes study on Health and Functioning during Infection Times - Children and Adolescents (COH-FIT-C&A)

BACKGROUND

The COVID-19 pandemic has altered daily routines and family functioning, led to closing schools, and dramatically limited social interactions worldwide. Measuring its impact on mental health of vulnerable children and adolescents is crucial.

METHODS

The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT - www.coh-fit.com) is an on-line anonymous survey, available in 30 languages, involving >230 investigators from 49 countries supported by national/international professional associations. COH-FIT has thee waves (until the pandemic is declared over by the WHO, and 6-18 months plus 24-36 months after its end). In addition to adults, COH-FIT also includes adolescents (age 14-17 years), and children (age 6-13 years), recruited via non-probability/snowball and representative sampling and assessed via self-rating and parental rating. Non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to promote health and prevent mental and physical illness in children and adolescents will be generated by COH-FIT. Co-primary outcomes are changes in well-being (WHO-5) and a composite psychopathology P-Score. Multiple behavioral, family, coping strategy and service utilization factors are also assessed, including functioning and quality of life.

RESULTS

Up to June 2021, over 13,000 children and adolescents from 59 countries have participated in the COH-FIT project, with representative samples from eleven countries.

LIMITATIONS

Cross-sectional and anonymous design.

CONCLUSIONS

Evidence generated by COH-FIT will provide an international estimate of the COVID-19 effect on children's, adolescents' and families', mental and physical health, well-being, functioning and quality of life, informing the formulation of present and future evidence-based interventions and policies to minimize adverse effects of the present and future pandemics on youth.

The collaborative outcomes study on health and functioning during infection times in adults (COH-FIT-Adults): Design and methods of an international online survey targeting physical and mental health effects of the COVID-19 pandemic

BACKGROUND

. High-quality comprehensive data on short-/long-term physical/mental health effects of the COVID-19 pandemic are needed.

METHODS

. The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT) is an international, multi-language (n=30) project involving >230 investigators from 49 countries/territories/regions, endorsed by national/international professional associations. COH-FIT is a multi-wave, on-line anonymous, cross-sectional survey [wave 1: 04/2020 until the end of the pandemic, 12 months waves 2/3 starting 6/24 months threreafter] for adults, adolescents (14-17), and children (6-13), utilizing non-probability/snowball and representative sampling. COH-FIT aims to identify non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to improve social/health outcomes in the general population/vulnerable subgrous during/after COVID-19. In adults, co-primary outcomes are change from pre-COVID-19 to intra-COVID-19 in well-being (WHO-5) and a composite psychopathology P-Score. Key secondary outcomes are a P-extended score, global mental and physical health. Secondary outcomes include health-service utilization/functioning, treatment adherence, functioning, symptoms/behaviors/emotions, substance use, violence, among others.

RESULTS

. Starting 04/26/2020, up to 14/07/2021 >151,000 people from 155 countries/territories/regions and six continents have participated. Representative samples of ≥1,000 adults have been collected in 15 countries. Overall, 43.0% had prior physical disorders, 16.3% had prior mental disorders, 26.5% were health care workers, 8.2% were aged ≥65 years, 19.3% were exposed to someone infected with COVID-19, 76.1% had been in quarantine, and 2.1% had been COVID 19-positive.

LIMITATIONS

. Cross-sectional survey, preponderance of non-representative participants.

CONCLUSIONS

. Results from COH-FIT will comprehensively quantify the impact of COVID-19, seeking to identify high-risk groups in need for acute and long-term intervention, and inform evidence-based health policies/strategies during this/future pandemics.

Sex-related differences in long-term mortality after coronary artery bypass graft surgery: a systematic review and meta-analysis

Background

This meta-analysis assessed the sex-related differences in long-term mortality (>7 years) after Coronary Artery Bypass Graft (CABG) Surgery.

Purpose

Women has higher incidence of short-term cardiovascular mortality after CABG compared to men. However, data about long-term differences are controversial.

Methods

We searched the databases for studies reporting sex-specific mortality following CABG including Ovid MEDLINE, Ovid, Embase, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL from inception up to December 31st, 2020. The search was not restricted to time or publication status. Outcomes included rates of long-term mortality (>7 year or longer).

Results

A total of 518 studies were resulted from literature search. A total of 14 studies and 204,223 patients; 158,663 men and 45,556 women, with a mean age of the men 60.2 years and 63.2 years for women, were included in our systematic review and meta-analysis. Our analysis suggested sex-related differences in long-term mortality (>7 years) following CABG (odds ratio (1), 1.15; 95% confidence interval (2), 1.017–1.30; P<.02).

Conclusions

Our results suggest that women had higher long-term mortality following CABG compared with men. It is the largest study to date of sex-specific differences in long-term mortality (>7 years).

Funding Acknowledgement

Type of funding sources: None. Meta-analysisDemographics

Efficacy and tolerability of lurasidone in schizophrenia: A systematic review and meta-analysis of short-term, randomized, placebo controlled trials

Introduction

Lurasidone is an atypical antipsychotic approved for the treatment of patients with schizophrenia. We report on a meta-analysis focusing on both the efficacy and safety/tolerability of lurasidone in the treatment of patients with schizophrenia.

Objectives

To obtain pooled estimates from placebo-controlled clinical trials on the efficacy and safety/tolerability of lurasidone in schizophrenia.

Methods

We selected acute, randomized placebo-controlled trials of lurasidone for schizophrenia. Primary outcome for efficacy was the Positive and Negative Syndrome Scale (PANSS) change and for “acceptability” was all-cause discontinuation. Secondary outcomes included specific adverse events, body weight change, ≥7% weight gain, and glucose and lipid parameter change.

Results

Across 10 RCTs (n=3,963, age=40.5±2.3 years, males=64.7 %, trial duration=6.0 weeks), lurasidone outperformed placebo regarding the PANSS total score (N=10, n=3,354, SMD=-0.34, 95% CI: -0.47−-0.21, p<0.001). Stratifying the analysis by dose, lurasidone significantly outperformed placebo at doses 40-160 mg/day. Lurasidone was associated with significantly lower all-cause discontinuation than placebo (N=10, n=3,410, RR=0.87, 95% CI: 0.78−0.97, p=0.014). Lurasidone had significantly higher body weight change compared with placebo (N=10, n=3,359, SMD=0.17, 95% CI: 0.09−0.24, p<0.001), but without significant differences regarding ≥7% body weight gain (N=9, n=3,186, p=0.112). Lurasidone did not differ from placebo in total cholesterol (N=10, n=3,140, p=0.439), LDL-cholesterol (N=7, n=2,414, p=0.849), triglycerides (N=10, n=3,140, p=0.238), and fasting glucose change (N=10, n=3,112, p=0.633).

Conclusions

In short-term trials, lurasidone was efficacious, acceptable and safe, having minimal effect on body weight gain and glucose and lipid metabolism.

Disclosure

K. Hagi is a full time employee of Sumitomo Dainippon Phrma Co., Ltd.

Safety of esketamine nasal spray: Analysis of post-marketing reports submitted to the FDA adverse event reporting system in the first year on the market

Introduction

The approval of the esketamine nasal spray for treatment-resistant depression in March 2019 by the Food and Drug Administration (FDA), and few months later by the European Medicine Agency, triggered a vivid debate and many concerns, mainly because of the lack of convincing evidence on its efficacy and safety, based on the development programs, approval trials and few post-marketing trials.

Objectives

We aimed to detect and characterize safety signals for esketamine, by analyzing relevant adverse events (AEs) reports in the FDA Adverse Event Reporting System (FAERS) database (March 2019-March 2020).

Methods

We performed disproportionality analysis through the case/non-case approach: reporting odds ratios (ROR) and information components (IC) with 95% confidence intervals (95%CI) were estimated for esketamine-related AEs with at least four counts. We compared serious and non-serious AEs using non-parametrical tests.

Results

The FAERS database registered 962 reports of esketamine-related AEs in one year. Signals (i.e., statistically significant disproportionality) were detected for several AEs, such as dissociation, sedation, feeling drunk, suicidal ideation and completed suicide. Signals for suicidal ideation, but not suicide attempt and completed suicide, remained significant when comparing esketamine to venlafaxine. The comparison of patients with serious vs. non-serious esketamine AEs revealed that females, patients receiving antidepressant polypharmacy, co-medication with antipsychotics, mood stabilizers, benzodiazepines or somatic medications were more likely to suffer from serious AEs.

Conclusions

This real-world pharmacovigilance analysis detected signals of serious unexpected esketamine-related AEs, thus reinforcing current worries regarding esketamine safety/acceptability. Further real-world studies are urgently needed to unravel the safety profile of esketamine.

Disclosure

No significant relationships.

Community health worker-delivered weight management intervention among public housing residents: A feasibility study

Community health worker-led interventions may be an optimal approach to promote behavior change among populations with low incomes due to the community health workers’ unique insights into participants’ social and environmental contexts and potential ability to deliver interventions widely. The objective was to determine the feasibility (implementation, acceptability, preliminary efficacy) of a weight management intervention for adults living in public housing developments. In 2016–2018, in Boston Massachusetts, we conducted a 3-month, two-group randomized trial comparing participants who received a tailored feedback report (control group) to participants who received the same report plus behavioral counseling. Community health workers provided up to 12 motivational interviewing-based counseling sessions in English or Spanish for diet and physical activity behaviors using a website designed to guide standardized content delivery. 102 participants enrolled; 8 (7.8%) were lost at 3-month follow up. Mean age was 46.5 (SD = 11.9) years; the majority were women (88%), Hispanic (67%), with ≤ high school degree (62%). For implementation, among intervention group participants (n = 50), 5 completed 0 sessions and 45 completed a mean of 4.6 (SD = 3.1) sessions. For acceptability, most indicated they would be very likely (79%) to participate again. For preliminary efficacy, adjusted linear regression models showed mean changes in weight (-0.94 kg, p = 0.31), moderate-to-vigorous physical activity (+11.7 min/day, p = 0.14), and fruit/vegetable intake (+2.30 servings/day, p < 0.0001) in the intervention vs. control group. Findings indicate a low-income public housing population was reached through a community health worker-led intervention with sufficient implementation and acceptability and promising beneficial changes in weight, nutrition, and physical activity outcomes.

Introduction of an assessment toolkit associated with increased rate of DLB diagnosis

Background

Dementia with Lewy bodies (DLB) and dementia in Parkinson’s disease (PDD) are recognised to be under-recognised in clinical practice in the UK, with only one third to a half of expected cases diagnosed. We aimed to assess whether clinical diagnostic rates could be increased by the introduction of a structured assessment toolkit for clinicians.

Methods

We established baseline diagnostic rates for DLB and PDD in four memory clinics and three movement disorder/Parkinson’s disease (PD) clinics in two separate geographical regions in the UK. An assessment toolkit specifically developed to assist with the recognition and diagnosis of DLB and PDD was then introduced to the same clinical teams and diagnostic rates for DLB and PDD were reassessed.

For assessing DLB diagnosis, a total of 3820 case notes were reviewed before the introduction of the toolkit, and 2061 case notes reviewed after its introduction. For PDD diagnosis, a total of 1797 case notes were reviewed before the introduction of the toolkit and 3405 case notes after it. Mean values and proportions were analysed using Student’s t test for independent samples and χ² test, respectively.

Results

DLB was diagnosed in 4.6% of dementia cases prior to the introduction of the toolkit, and 6.2% of dementia cases afterwards, an absolute rise of 1.6%, equal to a 35% increase in the number of DLB cases diagnosed when using the toolkit (χ² = 4.2, P = 0.041).

The number of PD patients diagnosed with PDD was not found overall to be significantly different when using the toolkit: 9.6% of PD cases before and 8.2% of cases after its introduction (χ² = 1.8, P = 0.18), though the ages of PD patients assessed after the toolkit’s introduction were lower (73.9 years vs 80.0 years, t = 19.2, p < 0.001).

Conclusion

Introduction of the assessment toolkit was associated with a significant increase in the rate of DLB diagnosis, suggesting that a structured means of assessing symptoms and clinical features associated with DLB can assist clinicians in recognising cases. The assessment toolkit did not alter the overall rate of PDD diagnosis, suggesting that alternate means may be required to improve the rate of diagnosis of dementia in Parkinson’s disease.

Examination of Food Insecurity, Socio-Demographic, Psychosocial, and Physical Factors among Residents in Public Housing

Objectives

Understanding associations between psychosocial and physical factors among those who experience food insecurity could help design effective food insecurity programs for improved cardiovascular health among low-income populations. We examined differences in psychosocial and physical factors between those who were food secure compared with food insecure among public housing residents.

Methods

Data were from the baseline survey of a randomized controlled trial of a weight management intervention in Boston, Massachusetts from 2016-2017. Food insecurity and psychosocial and physical factors, including perceived stress, personal problems, social support, and physical symptoms, were measured via interviewer-administered screeners.

Results

Mean age of the sample (N=102) was 46.5 years (SD=11.9). The majority were Hispanic (67%), female (88%), with ≤high school degree (62%). Nearly half were food insecure (48%). For psychosocial variables, those who were food insecure had higher ratings of perceived stress (adjusted mean difference 3.39, 95% CI:2.00,4.79), a higher number of personal problems (adjusted mean difference 1.85, 95% CI: 1.19, 2.51), and lower social support (adjusted mean difference -0.70, 95% CI:-1.30,-0.11) compared with those who were food secure. For physical variables, those who were food insecure had higher odds of reporting negative physical symptoms (aOR 4.92, 95% CI:1.84,13.16).

Conclusion

Among this sample of public housing residents, food insecurity was associated with higher stress, more personal problems, higher experiences of physical symptoms, and lower social support.

Sebelipase alfa for lysosomal acid lipase deficiency: 5-year treatment experience from a phase 2 open-label extension study

BACKGROUND AND AIMS

Lysosomal acid lipase deficiency is characterized by hepatomegaly and dyslipidaemia, which can lead to cirrhosis and premature atherosclerosis. Sebelipase alfa is an approved recombinant human lysosomal acid lipase. In an open-label extension study of adults with lysosomal acid lipase deficiency (LAL-CL04), sebelipase alfa treatment for 1 year reduced serum transaminase levels and liver fat content and improved serum lipid levels.

METHODS

Final data from LAL-CL04 are reported herein for patients who received sebelipase alfa infusions (1.0 or 3.0 mg/kg every other week) for up to 5 years.

RESULTS

Of 8 patients enrolled, 7 received sebelipase alfa for 224-260 weeks; 1 was lost to follow-up. Median baseline levels of alanine aminotransferase and aspartate aminotransferase (81.5 and 50.0 U/L, respectively) were decreased through the end-of-study visit (54.0 and 34.0 U/L). Median low-density lipoprotein cholesterol decreased from 113 to 78 mg/dL, total cholesterol decreased from 171 to 132 mg/dL, and high-density lipoprotein cholesterol increased from 37 to 42 mg/dL. Most treatment-emergent adverse events were nonserious (99%), mild/moderate (98%) and unrelated to sebelipase alfa (87%); no patient discontinued as a result of treatment-emergent adverse events. One patient had 2 serious treatment-emergent adverse events (cholecystitis and cholelithiasis; assessed as unlikely related to sebelipase alfa). Two patients had 20 nonserious infusion-associated reactions in weeks 6-38; all were manageable. One patient tested positive for antidrug antibodies (single occurrence).

CONCLUSIONS

Sebelipase alfa was well tolerated and improved serum transaminase and lipid levels for up to 5 years in adults with lysosomal acid lipase deficiency.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov record NCT01488097.

Bertiella sp. (Meyner, 1895) infection of Alouatta caraya (Humboldt, 1812) in urban and natural environments in Ñeembucú, southwest Paraguay

Bertiella sp., a cestode known to infect a variety of hosts, including nonhuman primates and humans, was identified in Paraguay as early as 1895, but no systematic analysis of wild primates' gastrointestinal parasites has ever been carried out in Paraguay. Increased urbanization in southwest Paraguay has pushed the Paraguayan howler monkey (Alouatta caraya) into anthropogenic habitats, particularly in the city of Pilar (Ñeembucú department), giving rise to greater potential for zoonotic transmission between wild primates and humans. From July to December 2018, fecal samples were noninvasively collected from 48 howlers inside Pilar (urban environment), the Pilar Military Base (intermediate environment), and a ranch 27 km outside Pilar in the humid Chaco (natural environment) and analyzed for Bertiella eggs and proglottids using macro-analysis and formol-ether sedimentation. Howlers living in the urban environment had the highest rates of Bertiella infection (50% prevalence), with considerably lower infection rates in the intermediate environment (6.25% prevalence) and natural habitats (0% prevalence). A χ² goodness-of-fit test indicated a significant difference between the three habitat types (p = .007, χ²  = 10.005, df = 2). While the habitat seems to impact the frequency of infection, Bertiella was not observed to select for other factors such as age or sex of the primate host. Here we identified a significant increase in the frequency of Bertiella infection in an urban environment, which can then be further transmitted to new hosts with more direct primate contact. Bertiella infection has already been documented in humans in Paraguay, all of which were associated with close primate contact. As howlers move into more urban habitats due to urbanization and habitat fragmentation, Bertiella could be introduced into this new ecosystem and has the potential to cause further infections in humans.

Acceptability of a 'treat to target' approach in inflammatory bowel disease to patients in clinical remission

BACKGROUND

A 'treat to target' approach aiming for remission of clinical symptoms and absence of mucosal inflammation has been proposed in inflammatory bowel disease (IBD). We aimed to establish whether patients with IBD in clinical remission find this approach acceptable.

METHODS

Patients in glucocorticosteroid-free clinical remission underwent a face-to-face structured, quantitative interview and rated the acceptability of treat to target on a 10-point Likert scale. We analysed factors associated with agreement to treat to target.

RESULTS

The cohort comprised 298 patients (144 Crohn's disease, 136 ulcerative colitis, 18 IBD-unclassified). Elevated C-reactive protein was found in 24.4% and elevated faecal calprotectin in 17.7%. Overall, 66.2% of patients rated a treat to target approach as acceptable (Likert scale ≥8). Acceptable treatment aims for patients were avoidance of flare, hospitalisation, surgery and colorectal cancer. Using binary logistic regression analysis the following were not predictive of accepting a treat to target approach: age, diagnosis, disease phenotype, surgical history, disease duration, patient knowledge, adherence, anxiety, depression and patient-reported control of disease. Better adherence to current therapy was associated with accepting a treat to target approach (B=0.16, p=0.039).

CONCLUSION

In a cohort of patients in clinical remission, where this strategy is most relevant, two-thirds of patients agreed with treat to target. Patients with better current adherence were more likely to accept treat to target. Patient education and counselling materials will need to be developed to convince a substantial minority of patients of the importance of treat to target.

Characterization of psychiatrically hospitalized college students

Objective: To characterize contemporary college students requiring psychiatric hospitalization. Participants and methods: Sociodemographic and diagnostic information was gathered retrospectively and analyzed from the electronic medical records (EMRs) of the consecutive inpatient hospitalizations of 905 college students admitted to a psychiatric inpatient unit. Results: Significantly more females compared to males experienced the following: more hospitalizations, more family and financial stressors, more depression, and less psychotic and bipolar disorder. The most frequent diagnosis was a depressive disorder, followed by bipolar disorder, psychotic disorder, and personality disorder, most frequently borderline personality disorder. Half of participants had comorbid diagnoses with substance abuse most common. More than two-thirds of students endorsed social or intimate relationship, academic, and family challenges as psychosocial stressors. In all, 15% of participants had repeat admissions. Conclusions: The present study provides demographic data from a sample of psychiatrically hospitalized college students. Findings can help improve screening and identification of decompensation in college students.

Twelve-Month Outcomes of a Group-Randomized Community Health Advocate-Led Smoking Cessation Intervention in Public Housing

Background

Lower rates of smoking cessation are a major reason for the higher prevalence of smoking among socioeconomically disadvantaged adults. Because barriers to quitting are both more numerous and severe, socioeconomically disadvantaged smokers may benefit from more intensive intervention. We sought to determine whether a smoking cessation intervention delivered by public housing residents trained as Tobacco Treatment Advocates (TTAs) could increase utilization of cessation resources and increase abstinence.

Methods

We conducted a group-randomized trial among Boston public housing residents who were interested in quitting smoking. Participants at control sites received standard cessation materials and a one-time visit from a TTA who provided basic counseling and information about cessation resources. Participants at intervention sites were eligible for multiple visits by a TTA who employed motivational interviewing, cessation counseling, and navigation to encourage smokers to utilize cessation treatment (Smokers' Quitline and clinic-based programs). Utilization and 7-day and 30-day point prevalence abstinence were assessed at 12 months. Self-reported abstinence was biochemically verified.

Results

Intervention participants (n = 121) were more likely than control participants (n = 129) to both utilize treatment programs (adjusted odds ratio [aOR]: 2.15; 95% confidence interval [CI]: 0.93-4.91) and 7-day and 30-day point prevalence abstinence (aOR: 2.60 (1.72-3.94); 2.98 (1.56-5.68), respectively). Mediation analysis indicated that the higher level of utilization did not explain the intervention effect.

Conclusions

An intervention delivered by peer health advocates was able to increase utilization of treatment programs and smoking abstinence among public housing residents. Future studies of similar types of interventions should identify the key mechanisms responsible for success.

Implications

In order to narrow the large and growing socioeconomic disparity in smoking rates, more effective cessation interventions are needed for low-income smokers. Individual culturally-relevant coaching provided in smokers' residences may help overcome the heightened barriers to cessation experienced by this group of smokers. In this study among smokers residing in public housing, an intervention delivered by peer health advocates trained in motivational interviewing, basic smoking cessation skills, and client navigation significantly increased abstinence at 12 months. Future research should address whether these findings are replicable in other settings both within and outside of public housing.

A meta-analysis of factors associated with quality of life in first episode psychosis

OBJECTIVE

Improving quality of life for people with first episode psychosis is an important aspect of recovery. Our objective was to review the associative factors on quality of life in first episode psychosis. A meta-analysis was conducted on the associations between quality of life, symptom severity, and duration of untreated psychosis.

METHOD

Fifty-one articles were identified (published through 08/29/2016) that provided data on the relationship between quality of life and at least one other outcome measure of interest in first episode psychosis. Of those studies, 21 were included in a meta-analysis (n = 3992) of the relationship between quality of life, severity of psychosis, and duration of untreated psychosis.

RESULTS

Meta-analysis identified significant negative correlations between quality of life and severity of symptoms (total symptom scores: r = -0.32, p < 0.001) and quality of life and duration of untreated psychosis (r = -0.21, p < 0.001). Heinrich's quality of life scale emerged as being more sensitive to the presence of psychotic symptoms than other measures of quality of life.

CONCLUSIONS

Associations were found between certain disease specific variables and quality of life in first episode psychosis, highlighting the relationship between symptom presentation and quality of life and the need for early intervention. Proper assessment of quality of life is important to promote improved quality of life in patients with first episode psychosis. Future research is needed to examine the interacting effects of symptom presentation, duration of untreated psychosis, and other variables, such as neurocognition, on quality of life.

Housing Quality and Mental Health: the Association between Pest Infestation and Depressive Symptoms among Public Housing Residents

Housing quality, which includes structural and environmental risks, has been associated with multiple physical health outcomes including injury and asthma. Cockroach and mouse infestations can be prime manifestations of diminished housing quality. While the respiratory health effects of pest infestation are well documented, little is known about the association between infestation and mental health outcomes. To address this gap in knowledge and given the potential to intervene to reduce pest infestation, we assessed the association between household pest infestation and symptoms of depression among public housing residents. We conducted a cross-sectional study in 16 Boston Housing Authority (BHA) developments from 2012 to 2014 in Boston, Massachusetts. Household units were randomly selected and one adult (n = 461) from each unit was surveyed about depressive symptoms using the Center for Epidemiologic Study-Depression (CES-D) Scale, and about pest infestation and management practices. In addition, a home inspection for pests was performed. General linear models were used to model the association between pest infestation and high depressive symptoms. After adjusting for important covariates, individuals who lived in homes with current cockroach infestation had almost three times the odds of experiencing high depressive symptoms (adjusted OR = 2.9, 95% CI 1.9-4.4) than those without infestation. Dual infestation (cockroach and mouse) was associated with over five times the odds (adjusted odds = 5.1, 95% CI 3.0-8.5) of experiencing high depressive symptoms. Using a robust measure of cockroach and mouse infestation, and a validated depression screener, we identified associations between current infestation and depressive symptoms. Although the temporal directionality of this association remains uncertain, these findings suggest that the health impact of poor housing conditions extend beyond physical health to include mental health. The study adds important information to the growing body of evidence that housing contributes to population health and improvements in population health may not be possible without addressing deficiencies in the housing infrastructure.

Subsidized Housing and Adult Asthma in Boston, 2010-2015

OBJECTIVES

To examine whether subsidized housing, specifically public housing and rental assistance, is associated with asthma in the Boston, Massachusetts, adult population.

METHODS

We analyzed a pooled cross-sectional sample of 9554 adults taking part in 3 Boston Behavioral Risk Factor Surveillance System surveys from 2010 to 2015. We estimated odds ratios for current asthma in association with housing status (public housing development [PHD] resident, rental assistance [RA] renter, non-RA renter, nonrenter nonowner, homeowner as reference) in logistic regression analyses adjusting for year, age, sex, race/ethnicity, education, and income.

RESULTS

The odds of current asthma were 2.02 (95% confidence interval [CI] = 1.35, 3.03) and 2.34 (95% CI = 1.60, 3.44) times higher among PHD residents and RA renters, respectively, than among homeowners. We observed smoking-related effect modification (interaction P = .04); elevated associations for PHD residents and RA renters remained statistically significant (P < .05) only among ever smokers. Associations for PHD residents and RA renters remained consistent in magnitude in comparison with non-RA renters who were eligible for subsidized housing according to income.

CONCLUSIONS

Public housing and rental assistance were strongly associated with asthma in this large cross-sectional sample of adult Boston residents.

Malignant adnexal tumors of the skin: a single institution experience

BACKGROUND

Malignant adnexal tumors of the skin (MATS) are rare. We aimed to measure the survival of patients with MATS and identify predictors of improved survival.

METHODS

A retrospective review of MATS treated at our institution from 1990 to 2012.

RESULTS

There were 50 patients within the time period. Median age was 59.5 years (range 22-95); primary site was the head and neck (52%); most common histologic subtypes were skin appendage carcinoma (20%) and eccrine adenocarcinoma (20%); and the vast majority were T1 (44%). Most patients (98%) underwent surgical treatment. Chemotherapy and radiation were administered to 8 and 14% of patients, respectively. Recurrence rate was 12%. Median OS was 158 months (95% CI, 52-255). OS and recurrence-free survival at 5 years were 62.4 and 47.4% and at 10 years 56.7 and 41.5%, respectively. Five-year and 10-year disease-specific survival (DSS) was 62.9%. Age > 60 years was an unfavorable predictor of OS (HR 12.9, P < .0008) and recurrence-free survival (RFS) (HR 12.53, P < .0003). Nodal metastasis was a negative predictor of RFS (HR 2.37, P < 0.04) and DSS (HR 7.2, P < 0.03) while treatment with chemotherapy was predictive of poor DSS (HR 14.21, P < 0.03).

CONCLUSIONS

Younger patients had better OS and RFS. Absence of nodal metastasis translated to better RFS and DSS. Lymph node basin staging is worth considering in the workup and treatment.

Predictors of aggression in 3.322 patients with affective disorders and schizophrenia spectrum disorders evaluated in an emergency department setting

INTRODUCTION

The aim of this study is to determine odds of aggression and associated factors in patients with schizophrenia-spectrum disorders (SSD) and affective disorders who were evaluated in an emergency department setting.

METHODS

A retrospective study was conducted using de-identified data from electronic medical records from 3.322 patients who were evaluated at emergency psychiatric settings. Data extracted included demographic information, variables related to aggression towards people or property in the past 6months, and other factors that could potentially impact the risk of aggression, such as comorbid diagnoses, physical abuse and sexual abuse. Bivariate analyses and multivariate regression analyses were conducted to determine the variables significantly associated with aggression.

RESULTS

An initial multivariate regression analysis showed that SSD had 3.1 times the odds of aggression, while bipolar disorder had 2.2 times the odds of aggression compared to unipolar depression. A second regression analysis including bipolar subtypes showed, using unipolar depression as the reference group, that bipolar disorder with a recent mixed episode had an odds ratio (OR) of 4.3, schizophrenia had an OR of 2.6 and bipolar disorder with a recent manic episode had an OR of 2.2. Generalized anxiety disorder was associated with lower odds in both regression analyses.

CONCLUSION

As a whole, the SSD group had higher odds of aggression than the bipolar disorder group. However, after subdividing the groups, schizophrenia had higher odds of aggression than bipolar disorder with a recent manic episode and lower odds of aggression than bipolar disorder with a recent mixed episode.

Effect of Epidural Volume Extension on Quality of Combined Spinal-Epidural Anesthesia for Cesarean Delivery: A Systematic Review and Meta-Analysis

In nonobstetric procedures, epidural volume extension (EVE) has been suggested to lower intraoperative opioid requirements while improving motor recovery when added to spinal anesthesia. This systematic review with meta-analysis was performed to evaluate the efficacy of EVE in elective cesarean delivery. We searched PubMed, Embase, and The Cochrane Review Database for randomized controlled trials evaluating EVE compared with single shot spinal and/ or combined spinal/epidural anesthesia. The primary outcomes were efficacy of EVE, as defined by the need for intraoperative opioid supplementation, and time to complete motor recovery. Eighteen randomized controlled trials consisting of 1,670 patients were evaluated. Subgroup analyses of EVE with local anesthetic were statistically significant in decreasing the need for intraoperative analgesic supplementation (risk ratio = 0.30; 95% confidence interval [CI] = 0.13-0.68; P = .004; I ² = 50%). Faster motor recovery was also seen (MD -24.14; 95% CI = -47.31 to -0.98; P = .04; I ² = 98%). Sequential EVE has been affirmed as a method to decrease intraoperative opioid requirements compared with single shot spinal or combined spinal/epidural anesthesia. Improved motor recovery times were also statistically significant but should be extrapolated with caution because of high heterogeneity of the included studies.

No Difference in Mood and Quality of Life in DHEA-S Deficient Adults with Addison's Disease vs. Type 2 Diabetes Patients with Normal DHEA-S Levels: Implications for Management of These Conditions

Patients with Addison's disease have relatively high rates of depression and anxiety symptoms compared with population-based reference samples. Addison's disease results in deficiency of dehydroepiandrosterone (DHEA) and DHEA-sulfate (DHEA-S). There is considerable debate about the specific effects of DHEA deficiency on energy level and mood. We measured emotional well-being in 16 patients with Addison's disease and a group of 16 hospital attendees with type 2 diabetes. Participants completed the General Health Questionnaire-28 (GHQ-28), the Hospital Anxiety and Depression Scale (HADS), the World Health Organization's quality of life assessment (WHOQOL-BREF) and the Holmes-Rahe life event scale. DHEA-S was low in Addison's patients (Addison's men: 0.5 ± 0.1 μmol/l [normal range: 2.1-10.8] compared with diabetes men: 3.2 ± 1.2 μmol/l; Addison's women: 0.4 ± 0.01 μmol/l [normal range: 1.0-11.5] compared with diabetes women: 2.2 ± 0.71 μmol/l). Testosterone levels were similar in both groups studied. There were no differences in emotional well-being and quality of life (QOL) between patients with Addison's disease and Type 2 Diabetes Mellitus as measured by GHQ-28 (Addison's: 22.4 ± 2.6, Diabetes: 19.6 ± 2.7), HADS Depression (Addison's: 5.4 ± 0.9, Diabetes: 4.5 ± 1.4), HADS Anxiety and WHOQOL-BREF. There were no gender differences in affective symptomatology within the Addison's group. Life event scores were above average in both groups (Addison's: 195 ± 39.6, Diabetes: 131 ± 43.8), but not significant for difference between groups as was GHQ-28 total score. Both groups scored highly on the GHQ-28 and the life event scale, indicative of poorer health perceptions than the general population. This could be due to the chronicity of both disorders. We have not identified any specific effects of DHEA-S deficiency on mood or QOL.

Behavioral Indicators on a Mobile Sensing Platform Predict Clinically Validated Psychiatric Symptoms of Mood and Anxiety Disorders

BACKGROUND

There is a critical need for real-time tracking of behavioral indicators of mental disorders. Mobile sensing platforms that objectively and noninvasively collect, store, and analyze behavioral indicators have not yet been clinically validated or scalable.

OBJECTIVE

The aim of our study was to report on models of clinical symptoms for post-traumatic stress disorder (PTSD) and depression derived from a scalable mobile sensing platform.

METHODS

A total of 73 participants (67% [49/73] male, 48% [35/73] non-Hispanic white, 33% [24/73] veteran status) who reported at least one symptom of PTSD or depression completed a 12-week field trial. Behavioral indicators were collected through the noninvasive mobile sensing platform on participants' mobile phones. Clinical symptoms were measured through validated clinical interviews with a licensed clinical social worker. A combination hypothesis and data-driven approach was used to derive key features for modeling symptoms, including the sum of outgoing calls, count of unique numbers texted, absolute distance traveled, dynamic variation of the voice, speaking rate, and voice quality. Participants also reported ease of use and data sharing concerns.

RESULTS

Behavioral indicators predicted clinically assessed symptoms of depression and PTSD (cross-validated area under the curve [AUC] for depressed mood=.74, fatigue=.56, interest in activities=.75, and social connectedness=.83). Participants reported comfort sharing individual data with physicians (Mean 3.08, SD 1.22), mental health providers (Mean 3.25, SD 1.39), and medical researchers (Mean 3.03, SD 1.36).

CONCLUSIONS

Behavioral indicators passively collected through a mobile sensing platform predicted symptoms of depression and PTSD. The use of mobile sensing platforms can provide clinically validated behavioral indicators in real time; however, further validation of these models and this platform in large clinical samples is needed.

Treatment-Resistant Schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) Working Group Consensus Guidelines on Diagnosis and Terminology

OBJECTIVE

Research and clinical translation in schizophrenia is limited by inconsistent definitions of treatment resistance and response. To address this issue, the authors evaluated current approaches and then developed consensus criteria and guidelines.

METHOD

A systematic review of randomized antipsychotic clinical trials in treatment-resistant schizophrenia was performed, and definitions of treatment resistance were extracted. Subsequently, consensus operationalized criteria were developed through 1) a multiphase, mixed methods approach, 2) identification of key criteria via an online survey, and 3) meetings to achieve consensus.

RESULTS

Of 2,808 studies identified, 42 met inclusion criteria. Of these, 21 studies (50%) did not provide operationalized criteria. In the remaining studies, criteria varied considerably, particularly regarding symptom severity, prior treatment duration, and antipsychotic dosage thresholds; only two studies (5%) utilized the same criteria. The consensus group identified minimum and optimal criteria, employing the following principles: 1) current symptoms of a minimum duration and severity determined by a standardized rating scale; 2) moderate or worse functional impairment; 3) prior treatment consisting of at least two different antipsychotic trials, each for a minimum duration and dosage; 4) systematic monitoring of adherence and meeting of minimum adherence criteria; 5) ideally at least one prospective treatment trial; and 6) criteria that clearly separate responsive from treatment-resistant patients.

CONCLUSIONS

There is considerable variation in current approaches to defining treatment resistance in schizophrenia. The authors present consensus guidelines that operationalize criteria for determining and reporting treatment resistance, adequate treatment, and treatment response, providing a benchmark for research and clinical translation.

Early intervention services in psychosis: from evidence to wide implementation

AIM

Early intervention (EI) in psychosis is a comprehensive and evidence-based approach aimed at detection and treatment of psychotic symptoms in their early stages. This paper presents core features and noteworthy aspects of the evidence basis and limitations of EI, the importance of programme fidelity, challenges for its widespread dissemination and economic perspectives related to it.

METHODS

This paper is a narrative review about the evidence supporting EI and the challenges to its widespread dissemination.

RESULTS

In spite of evidence of a wide range of benefits, widespread dissemination has been slow, and even currently implemented programmes might be threatened. This reflects in part the shortcomings of mental health care in general, such as low priority for funding, stigma and structural problems. Successful examples of advocacy, mobilization and destigmatization campaigns have overcome these difficulties.

CONCLUSIONS

Funding for mental health in general and for EI services appears low relative to need. One key argument for better funding for EI can be found in its favourable cost-effectiveness, but not all stakeholders beyond mental health administrators are aware of this. Positive impacts of EI programmes on excess unemployment and tax forgone suggest that social affairs and labour ministries - and not only health ministries - could be more involved in governance of mental health issues; ministries of justice and education are other sector stakeholders than can benefit. Wider dissemination of EI services will probably benefit from better integration of potential funders, promotion of joint targets and shared financial or budgetary incentives.

Impact of online resources and social media on help-seeking behaviour in youth with psychotic symptoms

AIM

The objective of the study was to explore the content of existing online resources available to information-seeking youth as psychotic symptoms first emerge and determine how these resources may influence initiation of care.

METHODS

Using 18 hypothetical search terms, developed by the Early Treatment Programme (ETP) staff, we searched three of the most popular websites used by the youth (Google, Facebook and Twitter) and extracted the first five hits from each. Sites were categorized into those that encouraged help seeking, those that potentially contribute to treatment delay, those with an undetermined impact and those that were unrelated to treatment.

RESULTS

An alarmingly few of the first five hits from the top three online resources encourage potentially psychotic youth to seek professional evaluation. The majority of our search results yielded unmonitored chat forums that lacked a unified message. The remainder promoted stigma, normalized potentially psychotic experiences or were completely unrelated to mental health.

CONCLUSION

We must develop innovative, easy-to-access and youth-focused online and social media experiences that encourage symptomatic youth to seek care.

Silent growth hormone secreting pituitary adenomas: IGF-1 is not sufficient to exclude growth hormone excess

Circulating insulin-like growth factor-1 (IGF-1) is increasingly being used as a screening test and in ongoing monitoring of treated acromegaly. We here present three cases of women (two of whom were on the oestrogen containing contraceptive pill at the time of presentation) who had normal circulating IGF-1 and no overt clinical features of acromegaly at the time of their pituitary surgery. Postoperatively, all were confirmed to have growth hormone excess in keeping with the presence of active somatotroph pituitary adenomas. We suggest that for optimal patient management, formal evaluation of growth hormone status with oral glucose tolerance testing should ideally be performed on all individuals for whom pituitary surgery is planned.

Measurement of serum testosterone in women; what should we do?

All immunoassays for female serum testosterone give falsely high results in some samples. The effect is variable and cannot be predicted for any given sample. Inaccurate calibration or interference by cross-reacting substances is almost certainly the cause of the problem, but for many immunoassays, the exact nature of the interferent is not known. Some of the interference can be removed by employing an extraction step prior to immunoassay. The advent of fast simple and sensitive liquid chromatography tandem mass spectrometry methods offers an exciting alternative to immunoassay for serum testosterone measurement. It is recommended that all high serum testosterone concentrations in women are checked, before reporting, by a method which is accurate (i.e. minimal bias to isotope dilution gas chromatography mass spectrometry [ID-GCMS] method) and is not subject to interference. Action should also be taken by assay users, manufacturers, regulators and professional bodies to ensure accurate standardization and comparability of assays.

Efficacy for Psychopathology and Body Weight and Safety of Topiramate-Antipsychotic Cotreatment in Patients With Schizophrenia Spectrum Disorders: Results From a Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To meta-analyze the efficacy and tolerability of topiramate-antipsychotic cotreatment in schizophrenia.

DATA SOURCES

PubMed/MEDLINE database were searched until September 5, 2015, using the keywords topiramate AND antipsych* OR neurolept* OR specific antipsychotic names.

STUDY SELECTION

Randomized controlled trials (RCTs) of topiramate-antipsychotic cotreatment versus placebo and ongoing antipsychotic treatment in patients with schizophrenia spectrum disorders were included.

DATA EXTRACTION

Two evaluators extracted data. Standardized mean difference (SMD), weighted mean difference (WMD), and risk ratio (RR) ± 95% CIs were calculated.

RESULTS

In 8 RCTs, lasting a mean ± SD of 13.6 ± 4.9 weeks, 439 patients were randomized to topiramate (100-400 mg/d) versus placebo (trials = 7) or ongoing antipsychotic treatment (trial = 1). Topiramate outperformed the comparator regarding total psychopathology (trials = 6, n = 269, SMD = -0.57 [95% CI, -1.01 to -0.14], P = .01), positive symptoms (trials = 4, n = 190, SMD = -0.56 [95% CI, -1.0 to -0.11], P = .01), negative symptoms (trials = 4, n = 190, SMD = -0.62 [95% CI, -1.13 to -0.10], P = .02) general psychopathology (trials = 3, n = 179, SMD = -0.69 [95% CI, -1.27 to -0.11], P = .02), body weight (trials = 7, n = 327, WMD = -3.14 kg [95% CI, -5.55 to -0.73], P = .01), and body mass index (BMI) (trials = 4, n = 198, WMD = -1.80 [95% CI, -2.77 to -0.84], P = .0003). Topiramate's efficacy for total psychopathology and weight reduction effects were not mediated/moderated by trial duration, topiramate dose, sex, age, inpatient status, baseline Positive and Negative Syndrome Scale, or baseline BMI. Conversely, clozapine-topiramate cotreatment moderated greater efficacy, but less weight loss, compared to topiramate-nonclozapine antipsychotic combinations. All-cause discontinuation was similar between topiramate and control groups (trials = 7, RR = 1.24 [95% CI, 0.76 to 2.02], P = .39). Topiramate trended only toward more paresthesia than placebo (trials = 4, RR = 2.03 [95 % CI, 0.99 to 4.18], P = .05).

CONCLUSIONS

Topiramate-antipsychotic cotreatment significantly reduced total, positive, negative, and general psychopathology and weight/BMI in patients with schizophrenia spectrum disorder while being well tolerated. However, larger studies are needed to confirm and extend these findings.

Whole-genome sequencing of a malignant granular cell tumor with metabolic response to pazopanib

Granular cell tumors are an uncommon soft tissue neoplasm. Malignant granular cell tumors comprise <2% of all granular cell tumors, are associated with aggressive behavior and poor clinical outcome, and are poorly understood in terms of tumor etiology and systematic treatment. Because of its rarity, the genetic basis of malignant granular cell tumor remains unknown. We performed whole-genome sequencing of one malignant granular cell tumor with metabolic response to pazopanib. This tumor exhibited a very low mutation rate and an overall stable genome with local complex rearrangements. The mutation signature was dominated by C>T transitions, particularly when immediately preceded by a 5' G. A loss-of-function mutation was detected in a newly recognized tumor suppressor candidate, BRD7. No mutations were found in known targets of pazopanib. However, we identified a receptor tyrosine kinase pathway mutation in GFRA2 that warrants further evaluation. To the best of our knowledge, this is only the second reported case of a malignant granular cell tumor exhibiting a response to pazopanib, and the first whole-genome sequencing of this uncommon tumor type. The findings provide insight into the genetic basis of malignant granular cell tumors and identify potential targets for further investigation.

Phase 2 Trial of an Alpha-7 Nicotinic Receptor Agonist (TC-5619) in Negative and Cognitive Symptoms of Schizophrenia

OBJECTIVES

This trial was conducted to test the effects of an alpha7 nicotinic receptor full agonist, TC-5619, on negative and cognitive symptoms in subjects with schizophrenia.

METHODS

In 64 sites in the United States, Russia, Ukraine, Hungary, Romania, and Serbia, 477 outpatients (18-65 years; male 62%; 55% tobacco users) with schizophrenia, treated with a new-generation antipsychotic, were randomized to 24 weeks of placebo (n = 235), TC-5619, 5mg (n = 121), or TC-5619, 50 mg (n = 121), administered orally once daily. The primary efficacy measure was the Scale for the Assessment of Negative Symptoms (SANS) composite score. Key secondary measures were the Cogstate Schizophrenia Battery (CSB) composite score and the University of California San Diego Performance-Based Skills Assessment-Brief Version (UPSA-B) total score. Secondary measures included: Positive and Negative Syndrome Scale in Schizophrenia (PANSS) total and subscale scores, SANS domain scores, CSB item scores, Clinical Global Impression-Global Improvement (CGI-I) score, CGI-Severity (CGI-S) score, and Subject Global Impression-Cognition (SGI-Cog) total score.

RESULTS

SANS score showed no statistical benefit for TC-5619 vs placebo at week 24 (5 mg, 2-tailed P = .159; 50 mg, P = .689). Likewise, no scores of CSB, UPSA-B, PANSS, CGI-I, CGI-S, or SGI-Cog favored TC-5619 (P > .05). Sporadic statistical benefit favoring TC-5619 in some of these outcome measures were observed in tobacco users, but these benefits did not show concordance by dose, country, gender, or other relevant measures. TC-5619 was generally well tolerated.

CONCLUSION

These results do not support a benefit of TC-5619 for negative or cognitive symptoms in schizophrenia.

Health Benefits of Green Public Housing: Associations With Asthma Morbidity and Building-Related Symptoms

OBJECTIVES

We examined associations of several health outcomes with green and conventional low-income housing, where the prevalence of morbidities and environmental pollutants is elevated.

METHODS

We used questionnaires and a visual inspection to compare sick building syndrome (SBS) symptoms and asthma-related morbidity among residents in multifamily units in Boston, Massachusetts, between March 2012 and May 2013. Follow-up was approximately 1 year later.

RESULTS

Adults living in green units reported 1.35 (95% confidence interval [CI] = 0.66, 2.05) fewer SBS symptoms than those living in conventional (control) homes (P < .001). Furthermore, asthmatic children living in green homes experienced substantially lower risk of asthma symptoms (odds ratio [OR] = 0.34; 95% CI = 0.12, 1.00), asthma attacks (OR = 0.31; 95% CI = 0.11, 0.88), hospital visits (OR = 0.24; 95% CI = 0.06, 0.88), and asthma-related school absences (OR = 0.21; 95% CI = 0.06, 0.74) than children living in conventional public housing.

CONCLUSIONS

Participants living in green homes had improved health outcomes, which remained consistent over the study period. Green housing may provide a significant value in resource-poor settings where green construction or renovation could simultaneously reduce harmful indoor exposures, promote resident health, and reduce operational costs.