Acute Angiotensin II Receptor Blockade Facilitates Parahippocampal Processing During Memory Encoding in High-Trait-Anxious Individuals

Background

Angiotensin II receptor blockers (ARBs) have been associated with preventing posttraumatic stress disorder symptom development and improving memory. However, the underlying neural mechanisms are poorly understood. This study investigated ARB effects on memory encoding and hippocampal functioning that have previously been implicated in posttraumatic stress disorder development.

Methods

In a double-blind randomized design, 40 high-trait-anxious participants (33 women) received the ARB losartan (50 mg) or placebo. At drug peak level, participants encoded images of animals and landscapes before undergoing functional magnetic resonance imaging, where they viewed the encoded familiar images and unseen novel images to be memorized and classified as animals/landscapes. Memory recognition was assessed 1 hour after functional magnetic resonance imaging. To analyze neural effects, whole-brain analysis, hippocampus region-of-interest analysis, and exploratory multivariate pattern similarity analysis were employed.

Results

ARBs facilitated parahippocampal processing. In the whole-brain analysis, losartan enhanced brain activity for familiar images in the parahippocampal gyrus (PHC), anterior cingulate cortex, and caudate. For novel images, losartan enhanced brain activity in the PHC only. Pattern similarity analysis showed that losartan increased neural stability in the PHC when processing novel and familiar images. However, there were no drug effects on memory recognition or hippocampal activation.

Conclusions

Given that the hippocampus receives major input from the PHC, our findings suggest that ARBs may modulate higher-order visual processing through parahippocampal involvement, potentially preserving intact memory input. Future research needs to directly investigate whether this effect may underlie the preventive effects of ARBs in the development of posttraumatic stress disorder.

PAX-D: study protocol for a randomised placebo-controlled trial evaluating the efficacy and mechanism of pramipexole as add-on treatment for people with treatment resistant depression

Introduction

Clinical depression is usually treated in primary care with psychological therapies and antidepressant medication. However, when patients do not respond to at least two or more antidepressants within a depressive episode, they are considered to have treatment resistant depression (TRD). Previous small randomised controlled trials suggested that pramipexole, a dopamine D2/3 receptor agonist, may be effective for treating patients with unipolar and bipolar depression as it is known to influence motivational drive and reward processing. PAX-D will compare the effects of pramipexole vs placebo when added to current antidepressant medication for people with TRD. Additionally, PAX-D will investigate the mechanistic effect of pramipexole on reward sensitivity using a probabilistic decision-making task.

Methods and analysis

PAX-D will assess effectiveness in the short- term (during the first 12 weeks) and in the longer-term (48 weeks) in patients with TRD from the UK. The primary outcome will be change in self-reported depressive symptoms from baseline to week 12 post-randomisation measured using the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16). Performance on the decision-making task will be measured at week 0, week 2 and week 12. Secondary outcomes include anhedonia, anxiety and health economic measures including quality of life, capability, well-being and costs. PAX-D will also assess the adverse effects of pramipexole including impulse control difficulties.

Discussion

Pramipexole is a promising augmentation agent for TRD and may be a useful addition to existing treatment regimes. PAX-D will assess its effectiveness and test for a potential mechanism of action in patients with TRD.

Trial registration number

ISRCTN84666271

Peripheral inflammation is associated with micro-structural and functional connectivity changes in depression-related brain networks

Inflammation is associated with depressive symptoms and innate immune mechanisms are likely causal in some cases of major depression. Systemic inflammation also perturbs brain function and microstructure, though how these are related remains unclear. We recruited N = 46 healthy controls, and N = 83 depressed cases stratified by CRP (> 3 mg/L: N = 33; < 3 mg/L: N = 50). All completed clinical assessment, venous blood sampling for C-reactive protein (CRP) assay, and brain magnetic resonance imaging (MRI). Micro-structural MRI parameters including proton density (PD), a measure of tissue water content, were measured at 360 cortical and 16 subcortical regions. Resting-state fMRI time series were correlated to estimate functional connectivity between individual regions, as well as the sum of connectivity (weighted degree) of each region. Multiple tests for regional analysis were controlled by the false discovery rate (FDR = 5%). We found that CRP was significantly associated with PD in precuneus, posterior cingulate cortex (pC/pCC) and medial prefrontal cortex (mPFC); and with functional connectivity between pC/pCC, mPFC and hippocampus. Depression was associated with reduced weighted degree of pC/pCC, mPFC, and other nodes of the default mode network (DMN). Thus CRP-related increases in proton density-a plausible marker of extracellular oedema-and changes in functional connectivity were anatomically co-localised with DMN nodes that also demonstrated significantly reduced hubness in depression. We suggest that effects of peripheral inflammation on DMN node micro-structure and connectivity may mediate inflammatory effects on depression.

A Dissociation of the Acute Effects of Bupropion on Positive Emotional Processing and Reward Processing in Healthy Volunteers

Background: Previous research indicates that antidepressants can restore the balance between negative and positive emotional processing early in treatment, indicating a role of this effect in later mood improvement. However, less is known about the effect of antidepressants on reward processing despite the potential relevance to the treatment of anhedonia. In this study, we investigated the effects of an acute dose of the atypical antidepressant (dual dopamine and noradrenaline reuptake inhibitor) bupropion on behavioral measures of emotional and reward processing in healthy volunteers. Methods: Forty healthy participants were randomly allocated to double-blind intervention with either an acute dose of bupropion or placebo prior to performing the Emotional Test Battery (ETB) and a probabilistic instrumental learning task. Results: Acute bupropion significantly increased the recognition of ambiguous faces as happy, decreased response bias toward sad faces and reduced attentional vigilance for fearful faces compared to placebo. Bupropion also reduced negative bias compared to placebo in the emotional recognition memory task (EMEM). There was no evidence that bupropion enhanced reward processing or learning. Instead, bupropion was associated with reduced likelihood to choose high-probability wins and increased score on a subjective measure of anhedonia. Conclusions: Whilst acute bupropion decreases negative and increases positive emotional processing, it has an adverse effect on reward processing. There seems to be a dissociation of the acute effects of bupropion on positive emotional processing and reward processing, which may have clinical implications for anhedonia early in treatment.

Allowing for non-adherence to treatment in a randomized controlled trial of two antidepressants (citalopram versus reboxetine): an example from the GENPOD trial

BACKGROUND

Meta-analyses suggest that reboxetine may be less effective than other antidepressants. Such comparisons may be biased by lower adherence to reboxetine and subsequent handling of missing outcome data. This study illustrates how to adjust for differential non-adherence and hence derive an unbiased estimate of the efficacy of reboxetine compared with citalopram in primary care patients with depression.

METHOD

A structural mean modelling (SMM) approach was used to generate adherence-adjusted estimates of the efficacy of reboxetine compared with citalopram using GENetic and clinical Predictors Of treatment response in Depression (GENPOD) trial data. Intention-to-treat (ITT) analyses were performed to compare estimates of effectiveness with results from previous meta-analyses.

RESULTS

At 6 weeks, 92% of those randomized to citalopram were still taking their medication, compared with 72% of those randomized to reboxetine. In ITT analysis, there was only weak evidence that those on reboxetine had a slightly worse outcome than those on citalopram [adjusted difference in mean Beck Depression Inventory (BDI) scores: 1.19, 95% confidence interval (CI) -0.52 to 2.90, p = 0.17]. There was no evidence of a difference in efficacy when differential non-adherence was accounted for using the SMM approach for mean BDI (-0.29, 95% CI -3.04 to 2.46, p = 0.84) or the other mental health outcomes.

CONCLUSIONS

There was no evidence of a difference in the efficacy of reboxetine and citalopram when these drugs are taken and tolerated by depressed patients. The SMM approach can be implemented in standard statistical software to adjust for differential non-adherence and generate unbiased estimates of treatment efficacy for comparisons of two (or more) active interventions.

SASOP Biological Psychiatry Congress 2013 Abstracts

<p><strong>List of abstracts and authors:</strong></p><p><strong>1. Bipolar disorder not otherwise specified -overdiagnosed or underdiagnosed?</strong></p><p>E Allers</p><p><strong>2. The prognosis of major depression untreated and treated: Does the data reflect the true picture of the prognosis of this very common disorder?</strong></p><p>E Allers</p><p><strong>3. Can we prolong our patients' life expectancy? Providing a better quality of life for patients with severe mental illness</strong></p><p>O A Betencourt</p><p><strong>4. The scope of ECT practice in South Africa</strong></p><p>J Benson-Martin, P Milligan</p><p><strong>5. Biomarkers for schizophrenia: Can we evolve like cancer therapeutics?</strong></p><p>P Buckley<strong></strong></p><p><strong>6. Relapse in schizophrenis: Major challenges in prediction and prevention</strong></p><p>P Buckley</p><p><strong>7. Informed consent in biological treatments: The right to know the duty to inform</strong></p><p><strong></strong>I Chetty</p><p><strong>8. Effectiveness of a long-acting injectable antipsychotic plus an assertive monitoring programme in first-episode schizophrenia</strong></p><p><strong></strong>B Chiliza, L Asmal, O Esan, A Ojagbemi, O Gureje, R Emsley</p><p><strong>9. Name, shame, fame</strong></p><p>P Cilliers</p><p><strong>10. Can we manage the increasing incidence of violent raging children? We have to!</strong></p><p>H Clark</p><p><strong>11. Serotonin, depression and antidepressant action</strong></p><p>P Cowen</p><p><strong>12. Prevalence and correlates of comorbid psychiatris illness in patients with heroin use disorder admitted to Stikland Opioid Detoxification Unit</strong></p><p>L Dannatt, K J Cloete, M Kidd, L Weich</p><p><strong>13. Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers</strong></p><p>A K Domingo, S Seedat, T M Esterhuizen, C Laurence, J Volmink, L Asmal</p><p><strong>14. Neuropeptide S -emerging evidence for a role in anxiety</strong></p><p>K Domschke</p><p><strong>15. Pathogenetics of anxiety</strong></p><p>K Domschke</p><p><strong>16. The effects of HIV on the fronto-striatal system</strong></p><p>S du Plessis, M Vink, J Joska, E Koutsilieri, C Scheller, B Spottiswoode, D Stein, R Emsley</p><p><strong>17. Effects of acute antipsychotic treatment on brain morphology in schizophrenia</strong></p><p>R Emsley, L Asmal, B Chiliza, S du Plessis, J Carr, A Goosen, M Kidd, M Vink, R Kahn</p><p><strong>18. Development of a genetic database resource for monitoring of breast cancer patients at risk of physical and psychological complications</strong></p><p>K Grant, F J Cronje, K Botha, J P Apffelstaedt, M J Kotze</p><p><strong>19. Unipolar mania reconsidered: Evidence from a South African study</strong></p><p><strong></strong>C Grobler</p><p><strong>20. Antipsychotic-induced movement disorders: Occurence and management</strong></p><p>P Haddad</p><p><strong>21. The place of observational studies in assessing the effectiveness of long-acting injectable antipsychotics</strong></p><p>P Haddad</p><p><strong>22. Molecular mechanisms of d-cycloserine in fear extinction: Insights from RNS sequencing</strong></p><p>S Hemmings, S Malan-Muller, L Fairbairn, M Jalali, E J Oakeley, J Gamieldien, M Kidd, S Seedat</p><p><strong>23. Schizophrenia: The role of inflammation</strong></p><p>DC Henderson</p><p><strong>24. Addictions: Emergent trends and innovations</strong></p><p>V Hitzeroth</p><p><strong>25. The socio-cultural-religious context of biological psychiatric practice</strong></p><p>B Janse van Rensburg</p><p><strong>26. Biochemical markers for identifying risk factors for disability progression in multiple sclerosis</strong></p><p><strong></strong>S Janse van Rensburg, M J Kotze, F J Cronje, W Davis, K Moremi, M Jalali Sefid Dashti, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus</p><p><strong>27. Alcohol-induced psychotic disorder: Brain perfusion and psychopathology - before and after antipsychotic treatment</strong></p><p>G Jordaan, J M Warwick, D G Nel, R Hewlett, R Emsley</p><p><strong>28.'Pump and dump': Harm reduction strategies for breastfeeding while using substances</strong></p><p>L Kramer</p><p><strong>29. Adolescent neuropsychiatry - an emerging field in South African adolescent psychiatric services</strong></p><p>A Lachman</p><p><strong>30. Recovery versus remission, or what it means to be healthy for a psychiatric patient?</strong></p><p>B Latecki</p><p><strong>31. Holistic methods utilised to normalise behaviours in youth diagnosed with neuro-biochemical disorders</strong></p><p>P Macqueen</p><p><strong>32. Candidate genes and novel polymorphisms for anxiety disorder in a South African cohort</strong></p><p>N McGregor, J Dimatelis, S M J Hemmings, C J Kinnear, D Stein, V Russel, C Lochner</p><p><strong>33. Higher visual functioning</strong></p><p>A Moodley</p><p><strong>34. The effects of prenatal methylmercury exposure on trace element and antioxidant levels in rat offspring following 6-hydroxydopamine-induced neuronal insult</strong></p><p>Z M Moosa, W M U Daniels, M V Mabandla</p><p><strong>35. Paediatric neuropsychiatric movement disorders</strong></p><p>L Mubaiwa</p><p><strong>36. The South African national female offenders study</strong></p><p>M Nagdee, L Artz, C de Clercq, P de Wet, H Erlacher, S Kaliski, C Kotze, L Kowalski, J Naidoo, S Naidoo, J Pretorius, M Roffey, F Sokudela, U Subramaney</p><p><strong>37. Neurobiological consequences of child abuse</strong></p><p>C Nemeroff</p><p><strong>38. What do Stellenbosch Unviversity medical students think about psychiatry - and why should we care?</strong></p><p>G Nortje, S Suliman, K Seed, G Lydall, S Seedat</p><p><strong>39. Neurological soft skins in Nigerian Africans with first episode schizophrenia: Factor structure and clinical correlates</strong></p><p><strong></strong>A Ojagbemi, O Esan, O Gureje, R Emsley</p><p><strong>40. Should psychiatric patients know their MTHFR status?</strong></p><p>E Peter</p><p><strong>41. Clinical and functional outcome of treatment refractory first-episode schizophrenia</strong></p><p>L Phahladira, R Emsley, L Asmal, B Chiliza</p><p><strong>42. Bioethics by case discussion</strong></p><p>W Pienaar</p><p><strong>43. Reviewing our social contract pertaining to psychiatric research in children, research in developing countries and distributive justice in pharmacy</strong></p><p>W Pienaar</p><p><strong>44. The performance of the MMSE in a heterogenous elderly South African population</strong></p><p>S Ramlall, J Chipps, A I Bhigjee, B J Pillay</p><p><strong>45. Biological basis addiction (alocohol and drug addiction)</strong></p><p>S Rataemane</p><p><strong>46. Volumetric brain changes in prenatal methamphetamine-exposed children compared with healthy unexposed controls</strong></p><p><strong></strong>A Roos, K Donald, G Jones, D J Stein</p><p><strong>47. Single voxel proton magnetic resonance spectroscopy of the amygdala in social anxiety disorder in the context of early developmental trauma</strong></p><p>D Rosenstein, A Hess, S Seedat, E Meintjies</p><p><strong>48. Discussion of HDAC inhibitors, with specific reference to supliride and its use during breastfeeding</strong></p><p>J Roux</p><p><strong>49. Prevalence and clinical correlates of police contact prior to a first diagnosis of schizophrenia</strong></p><p>C Schumann, L Asmal, K Cloete, B Chiliza, R Emsley</p><p><strong>50. Are dreams meaningless?</strong></p><p>M Solms</p><p><strong>51. The conscious id</strong></p><p>M Solms<strong></strong></p><p><strong>52. Depression and resilience in HIV-infected women with early life stress: Does trauma play a mediating role?</strong></p><p>G Spies, S Seedat</p><p><strong>53. State of affairs analysis for forensic psychiatry in SA</strong></p><p>U Subramaney</p><p><strong>54. Escitalopram in the prevention of post-traumatic stress disorder: A pilot randomised controlled trial</strong></p><p>S Suliman, S Seedat, J Pingo, T Sutherland, J Zohar, D J Stein</p><p><strong>55. Epigenetic consequences of adverse early social experiences in primates</strong></p><p>S Suomi</p><p><strong>56. Risk, resilience, and gene x environment interactions in primates</strong></p><p>S Suomi</p><p><strong>57. Biological aspects of anorexia nervosa</strong></p><p>C Szabo</p><p><strong>58. Agents used and profiles of non-fatal suicidal behaviour in East London</strong></p><p>H Uys</p><p><strong>59. The contributions of G-protein coupled receptor signalling to opioid dependence</strong></p><p>J van Tonder</p><p><strong>60. Emerging trend and innovation in PTSD and OCD</strong></p><p>J Zohar</p><p><strong>61. Making the SASOP treatment guidelines operational</strong></p><p>E Allers</p><p><strong>Poster Presentations</strong></p><p><strong>62. Neuropsychological deficits in social anxiety disorder in the context of early developmental trauma</strong></p><p><strong></strong>S Bakelaar, D Rosenstein, S Seedat</p><p><strong>63.Social anxiety disorder in patients with or without early childhood trauma: Relationship to behavioral inhibition and activation and quality of life</strong></p><p><strong></strong>S Bakelaar, C Bruijnen, A Sambeth, S Seedat</p><p><strong>64. Exploring altered affective processing in obssessive compulsive disorder symptom subtypes</strong></p><p>E Breet, J Ipser, D Stein, C Lochner<strong><br /></strong></p><p><strong>65. To investigate the bias toward recognising the facial expression of disgust in obsessive compulsive disorder as well as the effect of escitalopram</strong></p><p>E Breet, J Ipser, D Stein, C Lochner</p><p><strong>66. A fatal-case of nevirapine-induced Stevens-Johnson's syndrome in HIV mania</strong></p><p>A Bronkhorst, Z Zingela, W M Qwesha, B P Magigaba<strong></strong></p><p><strong>67. Association of the COMT G472A (met/met) genotype with lower disability in people diagnosed with multiple sclerosis</strong></p><p>W Davis, S J van Rensburg, L Fisher, F J Cronje, D Geiger, M J Kotze</p><p><strong>68. Homocycsteine levels are associated with the fat mass and obesity associated gene FTO(intron 1 T&gt;A) polymorphism in MS patients</strong></p><p>W Davis, S J Van Rensburg, M J Kotze, L Fisher, M Jalali, F J Cronje, K Moremi, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus</p><p><strong>69. Analysis of the COMT 472 G&gt;A (rs4680) polymorphism in relation to environmental influences as contributing factors in patients with schizophrenia</strong></p><p>D de Klerk, S J van Rensburg, R A Emsley, D Geiger, M Rensburg, R T Erasmus, M J Kotze</p><p><strong>70. Dietary folate intake, homocysteine levels and MTHFR mutation detection in South African patients with depression: Test development for clinical application </strong></p><p>D Delport, N vand der Merwe, R Schoeman, M J Kotze</p><p><strong>71. The use ofexome sequencing for antipsychotic pharmacogenomic applications in South African schizophrenia patients</strong></p><p>B Drogmoller, D Niehaus, G Wright, B Chiliza, L Asmal, R Emsley, L Warnich</p><p><strong>72. The effects of HIV on the ventral-striatal reward system</strong></p><p>S du Plessis, M Vink, J Joska, E Koutsilieri, C Scheller, B Spottiswoode, D Stein, R Emsley</p><p><strong>73. Xenomelia relates to asymmetrical insular activity: A case study of fMRI</strong></p><p>S du Plessis, M Vink, L Asmal</p><p><strong>74. Maternal mental helath: A prospective naturalistic study of the outcome of pregancy in women with major psychiatric disorders in an African country</strong></p><p>E du Toit, L Koen, D Niehaus, B Vythilingum, E Jordaan, J Leppanen</p><p><strong>75. Prefrontal cortical thinning and subcortical volume decrease in HIV-positive children with encephalopathy</strong></p><p>J P Fouche, B Spottiswoode, K Donald, D Stein, J Hoare</p><p><strong>76. H-magnetic resonance spectroscopy metabolites in schizophrenia</strong></p><p>F Howells, J Hsieh, H Temmingh, D J Stein</p><p><strong>77. Hypothesis for the development of persistent methamphetamine-induced psychosis</strong></p><p><strong></strong> J Hsieh, D J Stein, F M Howells</p><p><strong>78. Culture, religion, spirituality and psychiatric practice: The SASOP Spirituality and Psychiatry Special Interest Group Action Plan for 2012-2014</strong></p><p>B Janse van Rensburg</p><p><strong>79. Cocaine reduces the efficiency of dopamine uptake in a rodent model of attention-deficit/hyperactivity disorder: An <em>in vivo</em> electrochemical study</strong></p><p><strong></strong>L Kellaway, J S Womersley, D J Stein, G A Gerhardt, V A Russell</p><p><strong>80. Kleine-Levin syndrome: Case in an adolescent psychiatric unit</strong></p><p>A Lachman</p><p><strong>81. Increased inflammatory stress specific clinical, lifestyle and therapeutic variables in patients receiving treatment for stress, anxiety or depressive symptoms</strong></p><p>H Luckhoff, M Kotze, S Janse van Rensburg, D Geiger</p><p><strong>82. Catatonia: An eight-case series report</strong></p><p>M Mabenge, Z Zingela, S van Wyk</p><p><strong>83. Relationship between anxiety sensitivity and childhood trauma in a random sample of adolescents from secondary schools in Cape Town</strong></p><p>L Martin, M Viljoen, S Seedat</p><p><strong>84. 'Making ethics real'. An overview of an ethics course presented by Fraser Health Ethics Services, BC, Canada</strong></p><p>JJ McCallaghan</p><p><strong>85. Clozapine discontinuation rates in a public healthcare setting</strong></p><p>M Moolman, W Esterhuysen, R Joubert, J C Lamprecht, M S Lubbe</p><p><strong>86. Retrospective review of clozapine monitoring in a publica sector psychiatric hospital and associated clinics</strong></p><p>M Moolman, W Esterhuysen, R Joubert, J C Lamprecht, M S Lubbe</p><p><strong>87. Association of an iron-related TMPRSS6 genetic variant c.2007 C&gt;7 (rs855791) with functional iron deficiency and its effect on multiple sclerosis risk in the South African population</strong></p><p>K Moremi, S J van Rensburg, L R Fisher, W Davis, F J Cronje, M Jalali Sefid Dashti, J Gamieldien, D Geiger, M Rensburg, R van Toorn, M J de Klerk, G M Hon, T Matsha, S Hassan, R T Erasmus, M Kidd, M J Kotze</p><p><strong>88. Identifying molecular mechanisms of apormophine-induced addictive behaviours</strong></p><p>Z Ndlazi, W Daniels, M Mabandla</p><p><strong>89. Effects of lifestyle factors and biochemistry on the major neck blood vessels in patients with mutiple sclerosis</strong></p><p>M Nelson, S J van Rensburg, M J Kotze, F Isaacs, S Hassan</p><p><strong>90. Nicotine protects against dopamine neurodegenration and improves motor deficits in a Parkinsonian rat model</strong></p><p>N Ngema, P Ngema, M Mabandla, W Daniels</p><p><strong>91. Cognition: Probing anatomical substrates</strong></p><p>H Nowbath</p><p><strong>92. Chronic exposure to light reverses the effects of maternal separation on the rat prefrontal cortex</strong></p><p>V Russel, J Dimatelis</p><p><strong>93. Evaluating a new drug to combat Alzheimer's disease</strong></p><p>S Sibiya, W M U Daniels, M V Mabandla</p><p><strong>94. Structural brain changes in HIV-infected women with and without childhood trauma</strong></p><p>G Spies, F Ahmed, C Fennema-Notestine, S Archibald, S Seedat</p><p><strong>95. Nicotine-stimulated release of hippocampal norepinephrine is reduced in an animal model of attention-deficit/ hyperactivity disorder: the spontaneously hypertensive rat</strong></p><p>T Sterley</p><p><strong>96. Brain-derive neurotrophic factor (BDNF) protein levels in anxiety disorders: Systematic review and meta-regression analysis</strong></p><p>S Suliman, S M J Hemmings, S Seedat</p><p><strong>97. A 12-month retrospective audit of the demographic and clinical profile of mental healthcare users admitted to a district level hospital in the Western Cape, South Africa</strong></p><p>E Thomas, K J Cloete, M Kidd, H Lategan</p><p><strong>98. Magnesium recurarization: A comparison between reversal of neuromuscular block with sugammadex v. neostigmine/ glycopyrrolate in an <em>in vivo</em> rat model</strong></p><p><strong></strong>M van den Berg, M F M James, L A Kellaway</p><p><strong>99. Identification of breast cancer patients at increased risk of 'chemobrain': Case study and review of the literature</strong></p><p>N van der Merwe, R Pienaar, S J van Rensburg, J Bezuidenhout, M J Kotze</p><p><strong>100. The protective role of HAART and NAZA in HIV Tat protein-induced hippocampal cell death</strong></p><p>S Zulu, W M U Daniels, M V Mabandla</p>

Pindolol augmentation of serotonin reuptake inhibitors for the treatment of depressive disorder: a systematic review

Adding pindolol to serotonergic antidepressant treatment offers a potential strategy for producing a more rapid onset of action and an enhanced antidepressant effect. This review investigated whether pindolol enhances the efficacy of serotonergic antidepressant treatment in adult patients with depressive disorders at sequential time points up to 6 weeks.

SEARCH STRATEGY

Cochrane Collaboration Depression, Anxiety and Neurosis-Controlled Trials Register plus unpublished trial data.

STUDY SELECTION

Randomised trials including depressed patients, comparing serotonergic antidepressants + pindolol with serotonergic antidepressants + placebo and using depressive symptom clinical outcomes scales.

DATA EXTRACTION

Clinical response at time points up to 6 weeks as defined by >50% depression scale score reduction was extracted for each trial as possible. Eleven studies were identified including unpublished data. The pooled odds ratios for dichotomous response to treatment at time points from 1 to 6 weeks were 2.39 (95% CI 1.40-4.06), 2.39 (1.74-3.29), 1.94 (1.46-2.58), 1.59 (1.16-2.18), 1.42 (0.87-2.31) and 1.28 (0.91-1.81). Time-to-event analysis showed a greater response with pindolol augmentation versus placebo (P = 0.04). There was significant heterogeneity between studies at some time points. Dropout rates did not significantly differ between treatment arms. This review suggests an overall beneficial clinical effect of pindolol augmentation, most clearly up to 4 weeks of treatment.

Emotional face processing in women with high and low levels of eating disorder related symptoms

OBJECTIVES

Emotional processing has rarely been investigated in those "at risk" of developing an eating disorder. This study investigated the processing of six basic emotions depicted on faces in an "at risk" group, compared to a control group.

DESIGN

Participants were women with high (N=29) and low (N=23) levels of eating disorder symptoms who were not taking psychotropic medication. A well characterised computerised task (Facial Expression Emotion Task) was administered to all participants.

RESULTS

Women with high levels of eating disorder symptoms, compared to those with low levels, were less accurate at recognising happy and neutral faces, but showed no differences in their accuracy at recognising other emotions. They also showed a trend to be less good at discriminating anger, but better at discriminating surprise from other emotions. Depressive and anxious symptoms did not provide a complete explanation for the findings.

CONCLUSIONS

The findings support the inclusion of emotional processing in models of eating disorders, and suggest that it may have a role in their development. Emotional processing warrants further investigation particularly in those "at risk" but also in those with eating disorders.

Wake-up call for British psychiatry

The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty's future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty's core values and renew efforts to use psychiatric skills for the maximum benefit of patients.

Management of psoriasis

BACKGROUND

Psoriasis affects more than 6% of Australian adults. While rarely life threatening it can have an enormous psychosocial impact on sufferers.

OBJECTIVE

To outline the treatment options for psoriasis.

DISCUSSION

Localised psoriasis can usually be managed by topical therapy but more widespread psoriasis will require stronger treatments such as ultraviolet light, or various oral therapies. There is a great deal of psoriasis research underway and a number of new treatments have evolved over the past few years, some of which have yet to be released in Australia. As with any medical therapy the risks of the treatment must be weighed against the likely benefits. The patient needs to have an informed, sympathetic doctor to discuss the various available options.

A weighted composite dose-response model for human salmonellosis

This article describes the development of a weighted composite dose-response model for human salmonellosis. Data from previously reported human challenge studies were categorized into two different groups representing low and moderately virulent/pathogenic Salmonella strains based on a disease end point. Because epidemiological data indicate that some Salmonella strains are particularly pathogenic, and in the absence of human feeding study data for such strains, Shigella dysenteriae was used as a proxy for highly virulent strains. Three single-hit dose-response models were applied to the human feeding study data and evaluated for best fit using maximum likelihood estimation: (1) the exponential (E-1pop), (2) the two-subpopulation exponential (E-2pop), and (3) the Beta-Poisson (BP). Based on the goodness-of-fit test, the E-1pop and BP were the best-fit models for low and moderately virulent/pathogenic Salmonella strains, and the E-2pop and BP models were better for highly virulent/pathogenic strains. Epistemic analysis was conducted by determining the degree of confidence associated with the selected models, which was found to be 50%/50% (E-1pop/BP) for low and moderately pathogenic Salmonella strains, and 9.8%/90.2% (E-2pop/BP) for highly virulent strains. The degree of confidence for each component model and variations in the proportion of strains within each virulence/pathogenicity category were incorporated into the overall composite model. This study describes the influence of variation in strain virulence and host susceptibility on the shape of the population dose-response relationship.

Comparison of one week of oral terbinafine (250 mg/day) with four weeks of treatment with clotrimazole 1% cream in interdigital tinea pedis

Treatment of interdigital tinea pedis often involves long-term therapy with topically applied preparations. Effective oral preparations, such as the allylamine terbinafine (Lamisil), taken over a shorter period, could provide a useful therapeutic alternative. A total of 269 patients from five centres with clinically diagnosed interdigital tinea pedis were entered into this double-blind, randomized, double-dummy, parallel-group study comparing oral terbinafine 250 mg once daily for 1 week with 1% clotrimazole (Canesten) cream applied twice daily for 4 weeks. Of these, 137 patients were evaluable for efficacy (confirmed dermatophyte infection by microscopy and culture): 63 terbinafine and 74 clotrimazole. At week 4, the mycological cure rates (negative culture at week 1 and negative results on microscopy and culture at week 4 onwards) were very similar (71% for clotrimazole and 72% for terbinafine). There was a faster response rate in the terbinafine group with respect to signs and symptoms at week 1. Both treatments were equally well tolerated; adverse events occurred equally in the two groups. In conclusion, oral terbinafine in a single daily dose of 250 mg for 1 week is as effective and as well tolerated as 1% clotrimazole cream applied twice daily for 4 weeks in the treatment of interdigital tinea pedis.

Plasma levels of von Willebrand factor antigen in acute bronchitis and in a normal population

von Willebrand factor (vWF) is a large glycoprotein secreted predominantly by endothelial cells in both the systemic and pulmonary circulations and has a central role in the formation of the platelet plug. It has been put forward as a possible marker of endothelial cell injury, but is not ideal in that it is not specific for either the pulmonary or systemic circulation and may be released as part of the acute phase response from otherwise healthy endothelial cells. We undertook two studies (i) to assess within-subject to assess within-subject variation in plasma von Willebrand factor antigen (vWF:Ag) levels over time and to assess between-subject variation in a healthy patient population, and (ii) as part of a descriptive study of acute bronchitis, to assess whether plasma vWF:Ag levels altered in such a common and minor insult. A random sample of patients aged 45-74 years were taken from a local general practice. vWF:Ag levels were measured on three occasions, and spirometry was performed. The descriptive study was undertaken on patients in the general practice diagnosed with acute bronchitis without pre-existing pulmonary disease. Plasma vWF:Ag was measured on presentation and 14 and 42 days later. In 219 randomly selected patients the mean plasma vWF:Ag was similar at all three visits, the within-subject standard deviation being 0.09 U ml(-1) and 1.12 U ml(-1) respectively). There was no correlation between plasma vWF:Ag and C-reactive protein on presentation. We conclude that there is relatively little variation in an individual's plasma vWF:Ag level but that levels increase significantly with age. The observed elevation occurring with acute bronchitis is a true phenomenon; the absence of an associated acute phase response suggests that endothelial cell injury is the mechanism for the rise. These observations are important in the context of vWF as a marker of endothelial cell damage, as a common and supposedly minor insult such as acute bronchitis may markedly raise plasma levels.

Haber's syndrome

Haber's syndrome is a rare genodermatosis characterised by an early onset rosacea-like eruption associated with multiple truncal keratotic lesions. The present study reports the clinical presentation, histology and response to therapy of two cases of Haber's syndrome. The cases presented with the typical features of Haber's syndrome. Case 1 also had diffuse palmoplantar keratoderma and prominent nail cuticles, and case 2 had diffuse palmar keratoderma. These features have not been previously reported in Haber's syndrome. In the present study Haber's syndrome is reviewed, and its relationship to Dowling-Degos disease and acropigmentation of Kitamura are discussed.

Pityriasis rubra pilaris and focal acantholytic dyskeratosis

A 65-year-old man presented with a widespread erythematous maculopapular eruption. Skin biopsy showed spongiosis and focal acantholytic dyskeratosis consistent with Grover's disease. Clinically the eruption evolved to erythroderma with typical features of pityriasis rubra pilaris. On review of the histology, changes consistent with this diagnosis were also present in addition to the acantholytic dyskeratosis.

The relationship between asthma admission rates, routes of admission, and socioeconomic deprivation

This study aimed to explore the relationship between hospital admissions for asthma and socioeconomic deprivation. A retrospective study examined one year of hospital admissions for asthma in the West Midlands region of England (n = 10,044), and in one of the region's wealthier districts, Worcester (n = 251). Age standardized admission ratios (SARs) for asthma, and the routes of hospital admission, were compared with the Towns- end Deprivation Index for the place of residence. Asthma SAR was strongly associated with deprivation as measured by the Towns end Index for the district of residence (Spearman rank correlation coefficient rho = 0.65; p = 0.004). Asthma admission rates for all age groups, except those aged over 65 yrs, were higher in poorer districts. A significantly greater proportion of emergency admissions in poorer districts came via Accident and Emergency departments, rather than general practitioner referrals (rho = 0.76; p < 0.001). Within Worcester District, SAR was associated with Townsend Index for the ward of residence (rho = 0.39; p < 0.001). This remained significant after excluding repeat admissions (rho = 0.45; p < 0.001). We conclude that asthma admissions are strongly associated with deprivation in the community. Differences in the health care received during acute exacerbations by asthma patients from different economic backgrounds is likely to be an important factor in this relationship.

New horizons in the treatment of psoriasis and cutaneous fungal infections

This article takes a historical perspective and makes an assessment of current and future changes in the treatment of psoriasis and cutaneous fungal infections. Both medical and physical therapies in the management of psoriasis are reviewed and an assessment of the new approaches, compared with the old, is made. The vexing problem of cutaneous fungal infections is considered and the newer topical preparations are reviewed. With the arrival of these newer products improved outcomes for psoriasis and cutaneous fungal infections are being found.

Bullous pemphigoid in an infant

An acral blistering eruption in a 10 week old baby was found on histology and direct immunofluorescence to be bullous pemphigoid. Circulating auto-antibodies were not detected. He responded quickly to oral prednisolone and there have been no sequelae.

Developing an information resources management strategy for regulatory veterinary medicine: a national imperative

Lack of a standardized information technology management strategy has resulted in state and federal information systems evolving separately, rather than in tandem. Absence of an information management strategy will eventually affect regulatory program management, epidemiologic research, and domestic and international livestock trade. Producers will ultimately pay the price for the lack of regulatory coordination of US animal health and disease information. The longer the development of state and federal information technology management strategies is postponed, the more cost-, labor-, and time-intensive correcting the deficiency will be. Development of a national information resources management environment is the first step in constructing state and federal information technology strategies.

A research feasibility assessment of regulatory information systems capacities for investigation of epidemiologic factors in pseudorabies

Pseudorabies (PR) outbreak-investigation forms from 10 states having the most PR-infected herds were evaluated for agreement in question response-data type, information intent, and outbreak information categories. A question randomly selected from an investigation form had 0.6304 probability of being unique to a single state, and 0.0062 probability of being common to all states. Analysis of outbreak forms, on the basis of information intent, revealed that the probability of a randomly selected question being derived from an information category unique to a single state was 0.0323, whereas the probability of a question being derived from an information category shared by all states was 0.1935. A telephone survey revealed that state PR control officials did not believe additional research on between-herd spread of PR was necessary to successfully complete the eradication program. However, officials believed a better understanding of PR risk factors would enhance program effectiveness and build producer confidence.

Peritonitis in horses: 67 cases (1985-1990)

Peritonitis was diagnosed in 67 horses between 1985 and 1990: 14 horses developed septic peritonitis after intestinal rupture, 25 horses developed peritonitis after abdominal surgery, and 28 horses had peritonitis not associated with intestinal rupture or abdominal surgery. Forty of 67 horses (59.7%) did not survive. Nonsurvivors had higher heart rates (P = 0.01), RBC count (P = 0.039), serum creatinine concentration (P = 0.036), PCV (P = 0.007), and anion gap (P = 0.005); lower venous blood pH (P = 0.002); and a greater number of bacterial species cultured from peritoneal fluid samples (P = 0.054), compared with those from survivors. Nonsurvivors were more likely to have signs of abdominal pain (P < 0.000), circulatory shock (P = 0.009), and bacteria in peritoneal fluid samples (P = 0.042). Physical examination and peritoneal fluid analysis were the most valuable diagnostic aids for intestinal rupture. Peritonitis after abdominal surgery resulted in high mortality (56%); peritonitis not associated with intestinal rupture or abdominal surgery had lower mortality (42.9%). Clinical and laboratory indices can be of value in determining the prognosis for horses with peritonitis.

Low serum cholesterol and suicide

"Primary prevention trials which have shown that the lowering of serum cholesterol concentrations in middle-aged subjects by diet, drugs, or both leads to a decrease in coronary heart disease have also reported an increase in deaths due to suicide or violence. There has been no adequate explanation for this association. I have reviewed the relevant published work and describe a physiological mechanism that might account for this curious finding. One of the functions of serotonin in the central nervous system is the suppression of harmful behaviour impulses. When mouse brain synaptosomal membrane cholesterol is increased there is a pronounced increase in the number of serotonin receptors. Low membrane cholesterol decreases the number of serotonin receptors. Since membrane cholesterol exchanges freely with cholesterol in the surrounding medium, a lowered serum cholesterol concentration may contribute to a decrease in brain serotonin, with poorer suppression of aggressive behaviour".

A unique presentation of multicentric reticulohistiocytosis in pregnancy

We describe a patient with multicentric reticulohistiocytosis who presented, during the second trimester of pregnancy, with symmetric polyarthritis, marked erythematous, pulsatile synovial swelling of the distal interphalangeal joints of both hands, and widespread telangiectasias. She did not have the typical skin manifestations of multicentric reticulohistiocytosis. The erythema and pulsatility of the synovial swellings of the distal interphalangeal joints resolved after delivery, but she continued to have widespread active synovitis, which did not resolve until treatment with low-dose oral methotrexate was instituted.

Guidelines for treating depressive illness with antidepressants: A statement from the British Association for Psychopharmacology

Depression is a common illness which affects some 3% of the population per year. At least 25% of those with marked depression do not consult their general practitioner and in half of those who do the illness is not detected. Depression is easy to recognize when four or five of the core symptoms have been present for 2 weeks which often coincides with some occupational and social impairment. The core symptoms are depressed mood, loss of interest or pleasure, loss of energy or fatigue, concentration difficulties, appetite disturbance, sleep disturbance, agitation or retardation, worthlessness or self blame and suicidal thoughts. A diagnosis of depression is made when five of these core symptoms, one of which should be depressed mood or loss of interest or pleasure, have been present for 2 weeks. Four core symptoms are probably sufficient. Response to antidepressants is good in those with more than mild symptoms. When there are only few or very mild depressive symptoms evidence of response to antidepressants is more uncertain. Antidepressants are effective, they are not addictive and do not lose efficacy with prolonged use. The newer antidepressants have fewer side effects than the older tricyclics, they are better tolerated and lead to less withdrawals from treatment. They are less cardiotoxic and are safer in overdose. Antidepressants should be used at full therapeutic doses. Treatment failure is often due to too low a dose being used in general practice. It may be difficult to reach the right dose with the older tricyclics because of side effects. To consolidate response, treatment should be continued for at least 4 months after the patient is apparently well. Stopping the treatment before this is ill-advised as the partially treated depression frequently returns. Most depression is recurrent. Long-term antidepressant treatment is effective in reducing the risk of new episodes of depression and should be continued to keep the patient well.

Subcutaneous fat necrosis of the newborn complicated by hypercalcaemia and thrombocytopenia

Subcutaneous fat necrosis of the newborn is an uncommon but distinctive condition which appears in the first six weeks of life, associated with variable degrees of hypercalcaemia and which resolves spontaneously over months. We report a case of subcutaneous fat necrosis of the newborn following perinatal distress and complicated by thrombocytopenia and hypercalcaemia.

Fatal myocardial infarction and use of psychotropic drugs in young women

We have observed an unexpected 17-fold increase in risk of fatal [corrected] myocardial infarction (relative risk 16.9, 95% confidence interval 3.9-72.8) associated with current use of psychotropic drugs. This incidental finding, in a case-control study of cardiovascular mortality in women aged 16-39 not designed to test any hypothesis about psychotropic drugs, should be treated cautiously. There is, however, evidence of a relation between psychiatric morbidity and cardiovascular disease and the association recorded here requires further investigation.

Risk factors, clinical signs, and survival in cats with a clinical diagnosis of idiopathic hypertrophic cardiomyopathy: 74 cases (1985-1989)

Population characteristics, risk factors, and survival characteristics were evaluated in 74 cats with hypertrophic cardiomyopathy (HC) seen at North Carolina State University veterinary teaching hospital from 1985 to 1989, and compared with 82 clinically normal cats. The mean (+/- SD) age of cats with HC was 6.5 (4.0) years. Neutered males were at significantly greater risk (odds ratio 3.1) than neutered females. Breed, body weight, or coat color were not determined to be risk factors for HC. Tricolor cats were significantly underrepresented, probably reflecting the male predisposition for HC and not a true risk reduction associated with coat color. Forty-one cats were without clinical signs of heart disease (murmur and/or gallop sound only), 24 were in congestive heart failure, and 9 had systemic arterial embolism, 3 of which had concomitant congestive heart failure. The median survival time for 61 cats with HC, for which survival information could be obtained and that were not euthanatized on day 1, was 732 days. Survival was not affected by age at diagnosis, breed, body weight, or sex. However, clinical signs were important in determining prognosis; cats with heart rates greater than 200 beats/min survived significantly longer (median survival greater than 1,830 days) than those with heart rates greater than or equal to 200 beats/min (median survival = 152 days). Cats without clinical signs (median survival greater than 1,830 days) survived longer than those with clinical signs, and cats in heart failure survived a median of 92 days, compared with 61 days for those with systemic arterial embolism. Analysis of survival revealed no significant difference between the 2 groups of cats with clinical signs; however, all cats with embolism and only 60% of cats with heart failure were dead 6 months after diagnosis.

Benign neonatal hemangiomatosis

Three neonates with numerous cutaneous hemangiomas are presented. Although all three had serious medical problems, in none of these three could visceral hemangiomas be demonstrated. Neonatal hemangiomas can be restricted to the skin.

Effects of poult source on turkey production parameters

Flock records from a commercial turkey company were analyzed to determine if poult source affected flock performance. Comparisons were made between flocks supplied by two hatcheries (X and Y) reared on the same farms and among flocks reared on different farms. Flocks from hatchery X had significantly better livability and feed-conversion ratios than flocks from hatchery Y. Although not statistically significant, flocks from hatchery X tended to grade better at processing (percent grade A) and have lower condemnations than flocks from hatchery Y. Season significantly affected livability and feed conversion of all flocks regardless of hatchery source.

Survey of trichinosis in breeding and cull swine, using an enzyme-linked immunosorbent assay

Serum samples obtained from 40,927 swine at various locations in North Carolina between Aug 1, 1987 and July 31, 1988, were tested for antibodies to Trichinella spiralis, using an ELISA based on a larval T spiralis excretory-secretory antigen. In the ELISA, samples were considered to have positive results if the optical density (OD) reading was equal to or 5 times greater than the mean OD value of 4 negative-control sera from trichina-free swine. Of the 40,927 serum samples tested, 154 (0.38%) were positive by ELISA; the rate for breeding swine was 0.35% (105/30,162), and the rate for cull swine was 0.45% (49/10,765). Of the 49 seropositive samples from cull swine, 11 were from out of the state, 22 had no identification, and 16 were known to originate from North Carolina. Seropositivity had a bimodally seasonal distribution, with peaks in March and September. There was no difference between the mean age of seropositive and seronegative swine, but males were at greater risk for seropositivity than were females. Pigs from lots with less than 100 sera tested were at increased risk for seropositivity, as were pigs from the central coastal region of North Carolina.

Microscopy of skin scrapings for dermatophyte diagnosis

The correct technique for obtaining samples for microscopy and the proper preparation of the slide are important factors in obtaining an accurate result. The author discusses these components in detail and provides a pictorial display to aid in the interpretation of results.

Peripubertal human breast development

The microanatomical and histological appearance of the human breast has been studied during puberty. The macroscopic architecture of the mammary epithelial tree was identified and correlated with the histological appearance of material excised from defined regions of the breast preparations. Between ages 13 yrs and 15 yrs the human breast shows evidence of ductal elongation and branching, with lobules formed by lateral and dichotomous branching. The majority of ducts are lined by a two-layered epithelium consisting of recognisable myoepithelial and luminal cells. Less-well-defined multilayered regions were also observed in some areas, apparently at the site of lateral branching or early lobular development.

Reactivation of latent pseudorabies virus infection in vaccinated commercial sows

Pseudorabies virus (PRV) was isolated from 9 of 44 PRV-vaccinated seropositive sows on 5 of 11 farms. Although serum-neutralization antibody titers were 1:16 to 1:256, 28 virus isolates were obtained from tonsil, nasal, or buccal swab samples from 9 sows given 2 ml of dexamethasone/kg of body weight IM for 5 days. Pseudorabies virus was isolated from 6 of 20 sows (3 of 5 farms) given a killed-virus vaccination. Virus was obtained from 3 of 24 sows (2 of 6 farms) given modified-live virus and killed-virus vaccination. Evaluation of the 9 PRV with 5 restriction endonucleases revealed 4 PRV existing genotypes. The 9 isolated types of PRV appeared to be indistinguishable by Kpn I and BamHI restriction endonuclease analysis; however, when analyzed with Sal I, HinfI, and Pst I, isolates 7 (farm D), 8 (farm C), and 9 (farm B) had numerous differences. Isolates 1, 2, 3, and 4 (farm F) and 5 and 6 (farm G) appeared to be the same genotype when further analyzed with Pst I, HinfI, and Sal I.

Epidermodysplasia verruciformis

A patient with epidermodysplasia verruciformis was followed over a ten year period. This rare genetic disorder, characterised by papillomavirus-associated skin lesions and squamous cell carcinomas, is difficult to manage and invariably shortens the lifespan due to metastases from skin carcinomas. In our case, we confirmed the diagnosis using nucleic acid hybridisation, at high stringency, to cloned papillomavirus DNA. Relentless progression of disease occurred despite varied and increasingly vigorous treatment modalities.