Efficacy of Esketamine among patients with treatment resistant depression in a 'real world' health-care setting in Israel

One in five people will likely suffer from major depressive disorder (MDD) during their life. Thirty percent of those with MDD will experience Treatment Resistant Depression (TRD), which is characterized by a failure to respond to two adequately administered trials of antidepressants. Esketamine is a rapidly acting intranasal antidepressant. Present-day Esketamine research has limited data in real-world populations. This study aimed to assess Esketamine treatment in a real-world community-based population. This naturalistic retrospective study included 94 individuals age 18 and above diagnosed with TRD, treated with Esketamine in an outpatient setting. The treatment was given in a single clinic, from January 2021 to January 2023, following approval of the Institutional Internal Review Board. The treatment included an acute phase (biweekly treatment, continuing 4-8 weeks), followed by a maintenance phase (once a week to once a month, for 6-12 months). Dosing ranged from 28 mg to 84 mg. Demographic and clinical data were retrospectively gathered. Depressive symptoms were assessed using the Quick Inventory of Depressive Symptomatology, at baseline and during each treatment phase. All patients completed the acute phase. About 60% completed the maintenance phase. Linear improvement of depressive symptoms was revealed in both phases. A sub-analysis of patients with comorbid personality disorder revealed a similar improvement pattern in the acute phase with milder improvement during the maintenance phase, compared to the other patients. This study supports the use of Esketamine for TRD, including patients with comorbid personality disorder and previous electroconvulsive therapy.

The Effects of the 1st National COVID 19 Lockdown on Emergency Psychiatric Visit Trends in a Tertiary General Hospital in Israel

OBJECTIVE

To examine whether the 1^st COVID-19 lockdown in Israel affected emergency psychiatric presentations in a general hospital.

METHOD

We studied files of patients who underwent psychiatric consultation in the emergency-room (ER) at the Tel-Aviv Sourasky Medical Center during a lockdown imposed in 2020. Parallel data were obtained from 2017-2019, as control.

RESULTS

The number of psychiatric consultations dropped during the lockdown period; an increased relative number of compulsory psychiatric hospitalizations was documented and a decreased rate of consented psychiatric hospitalizations.

DISCUSSION

Less psychiatric patients approached the ER during the lockdown period, pointing to an urgent need to facilitate access to psychiatric care in future times of crisis.

Constitutive activation of sonic hedgehog signaling in the chicken mutant talpid(2): Shh-independent outgrowth and polarizing activity

We have examined the developmental properties of the polydactylous chicken mutant, talpid(2). Ptc, Gli1, Bmp2, Hoxd13, and Fgf4 are expressed throughout the anteroposterior axis of the mutant limb bud, despite normal Shh expression. The expression of Gli3, Ihh, and Dhh appears to be normal, suggesting that the Shh signaling pathway is constitutively active in talpid(2) mutants. We show that preaxial talpid(2) limb bud mesoderm has polarizing activity in the absence of detectable Shh mRNA. When the postaxial talpid(2) limb bud (including all Shh-expressing cells) is removed, the preaxial cells reform a normal-shaped talpid(2) limb bud (regulate). However, a Shh-expressing region (zone of polarizing activity) does not reform; nevertheless Fgf4 expression in the apical ectodermal ridge is maintained. Such reformed talpid(2) limb buds develop complete talpid(2) limbs. After similar treatment, normal limb buds downregulate Fgf4, the preaxial cells do not regulate, and a truncated anteroposterior deficient limb forms. In talpid(2) limbs, distal outgrowth is independent of Shh and correlates with Fgf4, but not Fgf8, expression by the apical ectodermal ridge. We propose a model for talpid(2) in which leaky activation of the Shh signaling pathway occurs in the absence of Shh ligand.

Mathematical modelling of 3-(3',4'-dichlorophenyl)-1,1-dimenthylurea action in plant leaves

A mathematical model of the action of a photosystem II herbicide 3-(3',4'-dichlorophenyl)-1, 1-dimenthylurea, DCMU, in plant leaves upon an external application is presented. The diffusion of DCMU in a plant tissue is described with the help of Fick's laws and the following reaction of the herbicide with the QB-binding site of photosystem II by the mass action theory. The model is used for a description of the effect of the herbicide on chlorophyll fluorescence induction (the O-J-I-P curve) measured with spring barley primary leaves submerged in the herbicide solution. The increase of the J step during the herbicide action is ascribed to an increase of the number of photosystem II centres with bound herbicide molecules and malfunctioning in the electron transport to the plastoquinone pool. The experimental data were fitted with the help of the mathematical model. Values of the diffusion coefficient and the second order rate constant of the reaction of the herbicide with photosystem II, obtained by the fitting procedure, are discussed.Copyright 1998 Academic Press Limited

Mathematical modelling of 3-(3',4'-dichlorophenyl)-1,1-dimenthylurea action in plant leaves

A mathematical model of the action of a photosystem II herbicide 3-(3',4'-dichlorophenyl)-1, 1-dimenthylurea, DCMU, in plant leaves upon an external application is presented. The diffusion of DCMU in a plant tissue is described with the help of Fick's laws and the following reaction of the herbicide with the QB-binding site of photosystem II by the mass action theory. The model is used for a description of the effect of the herbicide on chlorophyll fluorescence induction (the O-J-I-P curve) measured with spring barley primary leaves submerged in the herbicide solution. The increase of the J step during the herbicide action is ascribed to an increase of the number of photosystem II centres with bound herbicide molecules and malfunctioning in the electron transport to the plastoquinone pool. The experimental data were fitted with the help of the mathematical model. Values of the diffusion coefficient and the second order rate constant of the reaction of the herbicide with photosystem II, obtained by the fitting procedure, are discussed.Copyright 1998 Academic Press Limited

Relation between ambulatory electrocardiographic monitoring and myocardial perfusion imaging to detect coronary artery disease and myocardial ischemia: an ACIP ancillary study. The Asymptomatic Cardiac Ischemia Pilot (ACIP) Investigators

OBJECTIVES

This study sought to explore the relation between markers of ischemia detected by ambulatory electrocardiographic (AECG) monitoring and stress myocardial perfusion single-photon emission computed tomography (SPECT).

BACKGROUND

Stress myocardial SPECT and AECG monitoring are both utilized in evaluating patients with coronary artery disease. However, information is limited regarding the relation between the presence and extent of ischemia as detected by these two modalities.

METHODS

This was an ancillary study of the Asymptomatic Cardiac Ischemia Pilot (ACIP) trial. One hundred six patients with previous coronary angiography underwent AECG monitoring and stress SPECT within a close temporal time period. The frequency and duration of ischemia as assessed by AECG monitoring and the total and ischemic stress-induced myocardial perfusion defect sizes as assessed by SPECT were quantified in separate core laboratories. Multivariate logistic regression and linear regression analysis were used to determine associations between AECG and SPECT abnormalities with regard to angiographic, demographic and treadmill exercise variables.

RESULTS

Seventy-four percent of patients with significant (> or = 50%) coronary artery stenosis had SPECT abnormalities, whereas 61% had ischemia by AECG monitoring. The most important predictors of SPECT abnormalities were severity (p < 0.001) of coronary artery stenosis, followed by total exercise duration (p = 0.016) and patient age (p = 0.04). The only predictor of AECG abnormalities was the presence of ST segment depression on the initial exercise treadmill test (p = 0.021). Only a 50% concordance for normalcy or abnormalcy was observed between the SPECT and AECG results, and no relation was observed between the frequency or duration of AECG ischemia and the quantified total or ischemic myocardial perfusion defect size as assessed by SPECT.

CONCLUSIONS

Ischemia as detected by AECG monitoring does not correlate with the presence and extent of ischemia as quantified by stress SPECT. Because these techniques appear to detect different pathophysiologic manifestations of ischemia, they may be complementary in more fully defining the functional significance of coronary artery disease and, in particular, which patients are at highest risk for adverse cardiac events.

The role of glutamate 87 in the kinetic mechanism of Thermus thermophilus isopropylmalate dehydrogenase

The kinetic mechanism of the oxidative decarboxylation of 2R,3S-isopropylmalate by the NAD-dependent isopropylmalate dehydrogenase of Thermus thermophilus was investigated. Initial rate results typical of random or steady-state ordered sequential mechanisms are obtained for both the wild-type and two mutant enzymes (E87G and E87Q) regardless of whether natural or alternative substrates (2R-malate, 2R,3S-tartrate and/or NADP) are utilized. Initial rate data fail to converge on a rapid equilibrium-ordered pattern despite marked reductions in specificity (kcat/Km) caused by the mutations and alternative substrates. Although the inhibition studies alone might suggest an ordered kinetic mechanism with cofactor binding first, a detailed analysis reveals that the expected noncompetitive patterns appear uncompetitive because the dissociation constants from the ternary complexes are far smaller than those from the binary complexes. Equilibrium fluorescence studies both confirm the random binding of substrates and the kinetic estimates of the dissociation constants of the substrates from the binary complexes. The latter are not distributed markedly by the mutations at site 87. Mutations at site 87 do not affect the dissociation constants from the binary complexes, but do greatly increase the Michaelis constants, indicating that E87 helps stabilize the Michaelis complex of the wild-type enzyme. The available structural data, the patterns of the kinetics results, and the structure of a pseudo-Michaelis complex of the homologous isocitrate dehydrogenase of Escherichia coli suggest that E87 interacts with the nicotinamide ring.

Long-term survival and function after suspected gram-negative sepsis

OBJECTIVE

To determine the long-term (> 3 months) survival of septic patients, to develop mathematical models that predict patients likely to survive long-term, and to measure the health and functional status of surviving patients.

SETTING

A large tertiary care university hospital and an associated Veterans Affairs Medical Center.

DESIGN

From December 1986 to December 1990, a total of 103 patients with suspected gram-negative sepsis entered a double-blind, placebo-controlled efficacy trial of monoclonal antiendotoxin antibody. Of these, we followed up 100 patients for 7667 patient-months. Beginning in May 1992, we reviewed hospital records and contacted all known survivors. We measured the health status of all surviving patients.

MAIN OUTCOME MEASURES

The determinants of long-term survival (up to 6 years) were identified through two Cox proportional hazard regression models: one that included patient characteristics identified at the time of sepsis (bedside model) and another that included bedside, infection-related, and treatment characteristics (overall model).

RESULTS

Of the 60 patients in the cohort who died at a median interval of 30.5 days after sepsis, 32 died within the first month of the septic episode, seven died within 3 months, and four more died within 6 months. In the bedside multivariate model constructed to predict long-term survival, large hazard ratios (HRs) were associated with severity of underlying illness as classified by McCabe and Jackson criteria (for rapidly fatal disease, HR = 30.4, P < .001; for ultimately fatal disease, HR = 7.6, P < .001) and the use of vasopressors (HR = 2.5; P = .001). In the overall model for long-term survival, severity of underlying illness (rapidly fatal disease, HR = 23.7, P < .001; ultimately fatal disease, HR = 6.5, P < .001), number of active comorbid illnesses (HR = 1.3; P = .04), use of vasopressors at the time of sepsis (HR = 2.0; P = .02), and development of adult respiratory distress syndrome (HR = 2.3; P = .02) predicted patients most likely to die. The Acute Physiology and Chronic Health Evaluation II score was not a significant predictor of outcome when either model included the simpler McCabe and Jackson classification of underlying disease severity. We compared the health status scores with norms for the general population and found that patients with resolved sepsis reported more physical dysfunction (P < .001), including problems with work and activities of daily living (P = .02), and more poorly perceived general health (P < .01). In contrast, patients' scores for perceived emotional health were higher than those in the general population (P = .004). The mean Barthel score of our patients was 85 (100 = total independence) and the mean Eastern Cooperative Oncology Group score was 0.7 (0 = normal, 4 = 100% bedridden), suggesting that the patients' physical function was not normal.

CONCLUSIONS

At the onset of suspected gram-negative sepsis, severity of underlying illness and in-hospital use of vasopressors are strong and consistent predictors of short- and long-term survival. Our data validate the McCabe and Jackson severity of illness scoring system for predicting long-term survival after sepsis. Physical dysfunction and more poorly perceived general health occur commonly after sepsis.

The talpid2 chick limb has weak polarizing activity and can respond to retinoic acid and polarizing zone signal

The talpid2 (ta2) chick mutant has wide, polydactylous wings and legs. Talpid2 limb cartilages have abnormal morphology and a very subtle anteroposterior polarity. Specifically, posterior ta2 limb structures are identifiable, while more anterior cartilages are less distinctive. Here, we investigate the development of anteroposterior limb pattern in the ta2 embryo. We show that ta2 posterior limb bud mesoderm is capable of respecifying the anteroposterior axis of a normal wing. However, the average duplication obtained after grafting a ta2 polarizing region was significantly less than the average duplication formed after a graft of normal wing bud polarizing zone. Thus, polarizing activity appears to be weak in ta2. Grafts of normal polarizing zone to the posterior edge of ta2 wing buds had no effect on the ta2 phenotype. This result suggests that a weakly functioning polarizing signal does not account for the altered anteroposterior polarity in ta2 limbs, and that normal polarizing zone activity is not sufficient for formation of normal limb bud cartilages. We demonstrated that transmission of a polarizing signal through the ta2 limb mesoderm was normal. In addition, ta2 anterior border mesoderm had no polarizing activity. We also assessed the ability of ta2 limb bud mesoderm to respond to a polarizing signal. Either normal polarizing zone tissue or a bead containing retinoic acid was placed at the anterior edge of ta2 wing buds at stages 18-23. Both polarizing zone and retinoic acid caused respecification of the ta2 wing anteroposterior axis. The result was that a ta2 ulna replaced the radius, and the most posterior digit was duplicated anteriorly. Limb cartilages with normal morphology never formed. When a bead containing retinoic acid was placed at the posterior edge of ta2 wing buds, there was no effect on anteroposterior pattern. However, beads with retinoic acid always caused a reduction in the number of ta2 wing digits which formed, whether the beads were placed at the anterior or posterior edge of the developing ta2 limb.

Talpid2 mutant chick limb has anteroposterior polarity and altered patterns of programmed cell death

The talpid2(ta2) chick mutant is of interest for the study of limb pattern formation. Talpid2 is a simple Mendelian recessive lethal mutation which affects the mesoderm and results in short, spade-like, polydactylous wings and legs. Here, we describe ta2 limb development with particular attention to those aspects of ta2 which may illuminate the process of normal limb development. From the onset of budding, ta2 limb buds are significantly wider than normal buds along the anteroposterior axis. They lack the normal anterior and posterior necrotic zones and have variable development of the central opaque patch. Interdigital programmed cell death is variable and may result in development of distal phalanges without more proximal ones. Talpid2 wing vasculature is similar to that of normal wings; but ta2 legs are supplied by four large blood vessels. Feathers form regular, parallel rows, similar to normal feathers, but ta2 embryos lack the loose mesenchyme which separates the feather buds. Finally, and most significantly, ta2 wings and legs display anteroposterior polarity. Anterior and posterior limb skeletal elements can be clearly distinguished from one another within the ta2 phenotype. Our observations suggest that the ta2 mutant may be useful in analyzing programmed embryonic cell death and anteroposterior limb pattern formation.

The ability of the chick wing bud to regulate positional disparity along the anterior-posterior axis

When wedges of wing bud tissue are added to a host wing bud so there is positional disparity between graft and host, skeletal duplications result (L. E. Iten and D. J. Murphy 1980) Dev Biol. 75, 373-385. The polarity of the duplications is predictable by the polar coordinate model, leading to the interpretation that the positional disparity caused the duplications. To determine whether positional disparity alone causes duplications, without the complication of added tissue, we rotated wedges of ectoderm and mesoderm around the proximodistal axis within the wing bud. Wedges measuring 200-800 micron along the distal edge were rotated 180 degrees at stages 20-22, reversing the anteroposterior and dorsoventral axes relative to the bud. This caused positional disparity, similar to that achieved by Iten and Murphy (1980), without the addition of tissue. We found that rotations involving no polarizing zone tissue produced normal wings or wings lacking some distal parts, as did rotations of tissue lying entirely within the polarizing zone. However, when polarizing zone mesoderm was displaced, so that polarizing and nonpolarizing tissues were juxtaposed, a majority of the operations produced polarized skeletal duplications. Our data demonstrate that positional disparity alone does not cause skeletal duplications in the chick wing bud, unless polarizing zone tissue is displaced. Further, these data demonstrate that the chick wing bud can regulate to form a normal wing skeleton in the face of large positional disparity, provided that the polarizing zone is not moved. Finally, our results may be explained by the action of the proposed polarizing morphogen on the displaced cells causing repolarization.