Hikikomori: psychopathology and differential diagnosis of a condition with epidemic diffusion

OBJECTIVE

Hikikomori, from the Japanese words 'hiku' (to pull) and 'komoru' (to withdraw), is a clinical condition in which a subject locks himself/herself into his/her own house for more than 6 months. This condition is becoming relevant in Japan and other Asian countries, with new cases emerging in Europe and a steep increase in its incidence.

METHODS

In this article, the various psychopathological and diagnostic hypothesis and the different criteria proposed by the various authors have been analysed and compared, paying attention also to the new studies conducted in Europe and to therapeutic perspectives that are opening up for its treatment.

RESULTS

Numerous hypothesis have been put forward for the genesis of hikikomori, in particular, the hypothesis of a behaviour seen as a dysfuncion of the family system or as a result of our current modern society. Furthermore, this behaviour has been compared to other conditions such as internet addiction and a specific form of depression called Modern Type Depression (MTD).

CONCLUSIONS

Hikikomori could represent the clinical answer to a social evolution, similarly to other phenomena such as binge behaviours and use of psychoactive substances. Further studies are needed to clarify diffusion, diagnosticassessment and differential diagnosis.Key pointsHikikomori is now considered a contemporary society-bound syndrome linked to modern society changes.Hikikomori might be a coping strategy to avoid relationships, social judgement and possible failures.Hikikomori might represent an extreme suffering that needs to be identified early: it is linked to severe form of modern type depression and it is a risk factor for suicidal behaviours.It is important to inform and sensitise communities about hikikomori to assure early interventions.More clinical studies are needed to define a unitary and specific model of hikikomori and to structure focussed interventions.

Party Hard: Drug-related Fatalities in Ibiza from 2010 to 2016

Introduction

Illicit drug use is well known as an important contributor to the global burden of diseases, but the physical and psychopathological risks of recreational drugs misuse are often underestimated and drug-related fatalities in specific settings are under-investigated.

Objectives and methods

In the framework of the EU-funded project “EU-Madness”, we collected and analysed all the reports of drug-related fatalities in Ibiza from January 2010 to September 2016, with the aim of characterising the sample, and identifying the involved substances and the nature of deaths associated with their consumption.

Results

Overall, 58 drug-related fatalities were registered from 2010 to September 2016 (87.9% males, 12.1% females, mean age 33.16; females were significantly younger than males). Most of the deceased were Britons (36.2%), followed by Spanish (22.4%), Italians (6.9%) and Germans (5.2%). In half the cases, the substance identified in post-mortem analyses was a stimulant; in 24.1% of the sample it was a depressor a prescription drug or more than two substances in 22.4%. Most of the fatalities were due to cardiovascular accidents (62%); 22.4% were deaths by drowning, 12% by fall from heights and 3.4% were due to mechanical asphyxia.

Conclusions

According to the results from our sample, stimulants (mainly MDMA and cocaine) are the substances of abuse involved in most drug-caused fatalities. The number of fatalities per year has been steadily increasing, but the growing diffusion of novel psychoactive substances (NPS) does not seem to be a direct cause (although better methods of their analysis in post-mortem samples should be designed).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Augmenting pharmacotherapy with neuromodulation techniques for the treatment of bipolar disorder: a focus on the effects of mood stabilizers on cortical excitability

Introduction: Mood stabilizers and antipsychotics have been demonstrated to be effective in Bipolar Disorder, with lithium as the gold standard. However, the presence of adverse events and treatment-resistance is still a relevant issue. To this respect, the use of brain stimulation techniques may be considered as an augmentation strategy, with both Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS) having shown some level of efficacy in bipolar patients although clinical trials are still not sufficient to draw any conclusion. Areas covered: The authors have conducted a systematic review of the literature, in order to evaluate the role of mood stabilizers on neural activity and cortical excitability. Furthermore, the article reviews neuromodulation techniques and highlights the potential of integrating pharmacological first-line therapies with these techniques to treat BD patients. Expert opinion: The combination of neuromodulation techniques and available pharmacotherapies is a valuable opportunity which is not undermined by specific effects on cortical excitability and could improve BD patient outcome. Neurostimulation techniques may be considered safer than antidepressant treatments in BD, with a lower level of manic switches and may represent a new treatment strategy in BD depressive episodes.

The emergence of Exercise Addiction, Body Dysmorphic Disorder, and other image-related psychopathological correlates in fitness settings: A cross sectional study

INTRODUCTION

In a society that perpetuates the strive for a perfect appearance, a fit body has become synonymous with success, but simultaneously hard to achieve. This represents a fertile ground for the development of Exercise Addiction (EA) alongside other disorders, such as Body Dysmorphic Disorder (BDD). This study aims to explore the diffusion of EA in fitness settings in the United Kingdom, Italy, Netherlands, Hungary and the previously unexplored association with appearance anxiety, BDD, self-esteem and the use of fitness supplements.

METHODS

A large cross-sectional sample (N = 1711) was surveyed in fitness settings using the Exercise Addiction Inventory (EAI), Appearance Anxiety Inventory (AAI) and Rosenberg's Self Esteem Scale (RSE) in addition to questions surrounding the use of fitness supplements.

RESULTS

Compulsive exercise, appearance anxiety and low self-esteem were present in this sample according to the psychometric measures used (EAI, AAI, RSE). 11.7% scored over the cut off for EA, with alarming peaks in the Netherlands (20.9%) and the United Kingdom (16.1%). 38.5% were found at risk of BDD, mainly female (47.2%). 39.8% used fitness enhancing supplements without medical consultation (95.5%). This cohort of supplement users scored higher in both EAI and AAI. The logistic regression model revealed a strong association between the consumption of sport products and the level of EA across the sample with an odds ratio (OR) of 3.03. Other co-variable factors among female were appearance anxiety (AAI; OR 1.59) and to a lesser extent self-esteem (RSE) (OR 1.08).

CONCLUSIONS

This study identified a high risk of EA, appearance anxiety and BDD amongst a cohort of gym users internationally. The previously-unexplored association between these disorders and the unsupervised use of a variety of fitness products, including illicit drugs, highlights the need for informed and integrated responses targeting such vulnerable individuals.

rTMS Reduces Psychopathological Burden and Cocaine Consumption in Treatment-Seeking Subjects With Cocaine Use Disorder: An Open Label, Feasibility Study

Introduction: Cocaine use disorder (CUD) currently represents a notable public health concern, linked with significant disability, high chances of chronicity, and lack of effective pharmacological or psychological treatments. Repetitive transcranial magnetic stimulation (rTMS) is supposed to be a potential therapeutic option for addictive disorders. Aim of this study was to evaluate the feasibility of rTMS on (1) cocaine craving and consumption and (2) other comorbid psychiatric symptoms. Methods: Twenty treatment seeking CUD subjects underwent 2 weeks of intensive rTMS treatment (15Hz; 5 days/week, twice a day for a total of 20 stimulation sessions) of the left dorsolateral prefrontal cortex, followed by 2 weeks of maintenance treatment (15Hz, 1 day/week, twice a day). Sixteen patients completed the study. Patients were evaluated at baseline (T0), after 2 weeks of treatment (T1), and at the end of the study (T2; 4 weeks), with the following scales: Cocaine Selective Severity Assessment (CSSA), Zung Self-Rating Anxiety Scale, Beck Depression Inventory (BDI), Symptom Checklist-90 (SCL-90), and the Insomnia Severity Index. Results: After four weeks of rTMS treatment, 9 out of 16 subjects (56.25%) had a negative urinalysis test, with a significant conversion rate with respect to baseline (Z = -3.00; p = 0.003). Craving scores significantly improved only at T2 (p = 0.020). The overall psychopathological burden, as measured by the SCL-90 Global Severity Index (GSI), significantly decreased during the study period (Z = -2.689; p = 0.007), with a relevant improvement with regards to depressive symptoms, anhedonia, and anxiety. Subjects exhibiting lower baseline scores on the SCL-90 were more likely to be in the positive outcome group at the end of the study (Z = -3.334; p = 0.001). Discussion: Findings from this study are consistent with previous contributions on rTMS use in subjects with cocaine use disorder. We evidenced a specific action on some psychopathological areas and a consequent indirect effect in terms of relapse prevention and craving reduction. A double-blind, sham-controlled, neuro-navigated rTMS study design is needed, in order to confirm the potential benefits of this technique, opening new scenarios in substance use disorders treatment.

A New SERPINA-1 Missense Mutation Associated with Alpha-1 Antitrypsin Deficiency and Bronchiectasis

Alpha-1-antitrypsin deficiency (AATD) is a genetic condition caused by SERPINA1 mutations, which culminates into lower protease inhibitor activity in the serum and predisposes to emphysema. Clinical manifestations of AATD are often associated to ZZ (p.Glu342Lys) and SZ (p.Glu264Val) genotypes and less frequently to rare deficiency or null alleles in heterozygous and homozygous states. We report a case of a 52-year-old woman with bronchiectasis without other potential causes other than an electrophoresis that showed a decrease of alpha-1 globin band and AAT levels below the normal value (78 mg/dl; v.n. 90-200 mg/dl). No S or Z mutation was identified, but sequencing analysis found a novel missense variant Ile74Asn (c.221T > A) in heterozygous state on an M3 allele (Glu400Asp) in the exon 2 of the SERPINA-1gene, probably leading to a dysfunctional protein. This mutation has never been previously identified, and it is interesting to note the association with bronchiectasis in the absence of emphysema.

Changing trends in the use of kratom (Mitragyna speciosa) in Southeast Asia

OBJECTIVE

Kratom (Mitragyna speciosa. Korth) is an indigenous medicinal plant of Southeast Asia. This review paper aims to describe the trends of kratom use in Southeast Asia.

DESIGN

A literature review search was conducted through ScienceDirect, Scopus, ProMed and Google Scholar. Twenty-five articles illustrating kratom use in humans in Southeast Asia were reviewed.

RESULTS

Kratom has long been used by rural populations in Southeast Asia as a remedy for common ailments, to fight fatigue from hard manual work, as a drink during social interaction among men, and in village religious functions. Studies based on self-reports suggest that prolonged kratom use does not result in serious health risks or impair social functioning. Two recent trends have also emerged: (a) Kratom is reportedly being used to ease withdrawal from opioid dependence in rural settings; whereas (b) in urban areas, adulterated kratom cocktails are being consumed by younger people to induce euphoria.

CONCLUSIONS

Legal sanctions appear to have preceded serious scientific investigations into the claimed benefits of ketum. More objective-controlled trials and experiments on humans need to be conducted to validate self-report claims by kratom users in the community.

A matter of life and death: substance-caused and substance-related fatalities in Ibiza in 2015

OBJECTIVES AND METHODS

In the framework of the EU-funded project "EU-Madness," we collected and analysed all the reports of fatalities directly or indirectly related to substances of abuse registered in Ibiza from January to September 2015, in order to analyse the characteristics of the sample, the identified substances, and the nature of deaths associated with their consumption.

RESULTS

A significant increase of substance-caused deaths with respect to the previous 4 years has been highlighted. Most of the subjects were young males, more than half were not Spanish. Males prevailed also amongst the victims of traffic accidents and suicides. The most commonly involved substances included MDMA, alcohol, cocaine, THC, opiates and prescription drugs.

CONCLUSIONS

Although the use of NPS is rapidly increasing in Europe, according to the results from our sample, alcohol and well-known stimulants (MDMA and cocaine) are still the substances of abuse mainly involved in the cases of substance-caused and substance-related fatalities. The significant increase of fatalities in Ibiza in the last 5 years is an issue that must be taken into account and should be better investigated, as other theories besides NPS-increased diffusion should be proposed, and therefore, targeted prevention strategies should be designed.

Novel psychoactive substance consumption is more represented in bipolar disorder than in psychotic disorders: A multicenter-observational study

OBJECTIVE

Comorbidities between psychiatric diseases and use of traditional substances of abuse are common. Nevertheless, there are few data regarding the use of novel psychoactive substances (NPS) among psychiatric patients. Aim of this multicentre survey is to investigate the consumption of a number of psychoactive substances in a young psychiatric sample.

METHODS

Between December 2013 and September 2015, a questionnaire was administered in 10 Italian psychiatric care facilities to a sample of 671 patients, aged 18-26 (mean age 22.24; SD 2.87).

RESULTS

About 8.2% of the sample declared to have used NPS at least once, and 2.2% had consumed NPS in the previous 3 months. The three psychiatric diagnoses most frequently associated with NPS use were bipolar disorder (23.1%), personality disorders (11.8%), and schizophrenia and related disorders (11.6%). In univariate regression analysis, bipolar disorder was positively associated with NPS consumption, an association that did not reach statistical significance in the multivariate analysis.

CONCLUSIONS

The use of NPS in a young psychiatric population appears to be frequent, and probably still underestimated. Bipolar disorder shows an association with NPS use. Careful and constant monitoring and an accurate evaluation of possible clinical effects related to NPS use are necessary.

Substance-related psychopathology and aggressiveness in a nightlife holiday resort: Results from a pilot study in a psychiatric inpatient unit in Ibiza

OBJECTIVES

We aimed to describe a sample of subjects admitted to a psychiatric unit after the intake of psychoactive substances for recreational purposes.

METHODS

Between June and September 2015, 49 subjects were included. Sociodemographic characteristics and psychopathological aspects were investigated, and urine samples for further analysis were collected. Three subgroups (cannabinoids, stimulants, and depressors users) were identified, according to the structured interview regarding substance use and urinalysis.

RESULTS

Level of aggressiveness was found to be significantly higher (p < .05) in the cannabinoids subgroup. Self-reported symptom severity was comparable among groups, but trends could be identified: SCL-90 results showed a prevalence of anxiety symptoms among depressors users, hostility or aggression in the tetrahydrocannabinol subgroup, and psychoticism in the stimulants subgroup.

CONCLUSIONS

The use of psychoactive substances was be characterised by poly-use of both traditional and novel substances. The presence of aggressiveness emerged as a main feature associated with the use of cannabis and other cannabinoids. Binge drinking and sleep deprivation also represented a relevant component in almost all the evaluated subjects.

Can mobile phone technology support a rapid sharing of information on novel psychoactive substances among health and other professionals internationally?

BACKGROUND

The diffusion of novel psychoactive substances (NPSs), combined with the ability of the Internet to act as an online marketplace, has led to unprecedented challenges for governments, health agencies, and substance misuse services. Despite increasing research, there is a paucity of reliable information available to professionals working in the field. The paper will present the pilot results of the first mobile application (SMAIL) for rapid information sharing on NPSs among health professionals.

METHODS

The development of SMAIL was divided into 2 parts: (a) the creation of the application for registered users, enabling them to send an SMS or email with the name or "street name" of an NPS and receive within seconds emails or SMS with the information, when available and (b) the development of a database to support the incoming requests.

RESULTS

One hundred twenty-two professionals based in 22 countries used the service over the pilot period of 16 months (from May 2012 to September 2013). Five hundred fifty-seven enquires were made. Users received rapid information on NPSs, and 61% of them rated the service as excellent.

CONCLUSIONS

This is the right time to use mobile phone technologies for rapid information sharing and prevention activities on NPSs.

Captagon: use and trade in the Middle East

BACKGROUND

Fenetheylline, a psychostimulant drug, often branded as Captagon, is a combination of amphetamine and theophylline. Since the cessation of its legal production in 1986, counterfeited products have been produced illicitly in south-east Europe and far-east Asia. Its profitable trade has been linked to terrorist organizations, including Islamic State of Iraq and the Levant. This study aims to reach up-to-date data, concerning the Captagon e-commerce and use in the Middle East.

METHODS

A multi-staged and multi-lingual literature search was carried out. A list of prespecified keywords was applied across medical and paramedical databases, web and Dark web, search engines, social communication media, electronic commerce websites, media networks, and the Global Public Health Intelligence Network database.

RESULTS

The use of Captagon as a stimulant in terrorist settings has been marginally covered in the literature. Data can widely be retrieved from Google and AOL search engines, YouTube, and Amazon e-commerce websites, and to a lesser extent from Alibaba and eBay. On the contrary, Middle Eastern e-commerce websites yielded almost no results. Interestingly, the Dark web generated original data for Captagon e-commerce in the Middle East.

CONCLUSION

Further investigations are needed on the role that psychoactive drugs play in terrorist attacks and civil war zones. Unless a comprehensive methodological strategy, inclusive of unconventional methods of research, is implemented, it will not be feasible to face such a threat to humanity.

Role of Co-occurring Alcohol and Substances Abuse on QTc Interval Prolongation Among Psychiatric Patients: A Cross-sectional National Survey

Introduction

QTc interval prolongation is considered a risk factor for fatal polymorphic ventricular tachycardia, which can result in sudden cardiac death. Most psychotropic drugs have a dose-dependent potential to prolong the QTc interval. However, other factors require appropriate consideration, including: age; gender; other medications; electrolyte abnormalities; severe comorbid conditions, such as co-occurring alcohol or substances abuse/dependence.

Objectives

The objective was to study the potential mediating roles of alcohol/substances abuse on QTc prolongation.

Aims

The Italian research group STAR Network, in collaboration with the Young Italian Psychiatrists Association, aimed to evaluate the frequency of QTc interval prolongation in a sample of patients under treatment with psychotropic drugs through a cross-sectional national survey.

Methods

A sample of 2411 unselected patients were enrolled after performing an ECG during the recruitment period. Sociodemographic and clinical characteristics were collected from medical records. Collected data underwent statistical analysis.

Results

A total of 11.2% of patients reported alcohol abuse, and only 8.9% psychotropic substances. According to the threshold, less than 20% of patients had a borderline value of QTc, and 1% a pathological value. Patients with co-occurring alcohol misuse and drug abuse were more likely to have longer QTc interval.

Conclusions

The present study describes the frequency of QTc prolongation in real-world clinical practice. Before prescribing a psychotropic drug, the physician should carefully assess its risks and benefits to avoid this type of adverse reaction, particularly when additional risk factors are present. The potential role of alcohol and substances on QTc length could be particularly useful in emergency settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Traumatic Experiences Affect Negative Emotion Processing in Bipolar Disorder

Introduction

Patients affected by bipolar disorder type I (BD-I) show a significant emotional impairment during both acute and euthymic phases of the illness, but the influence of negative life experiences is not yet fully understood.

Objectives

Aim of the present study was to investigate the role of previous traumatic events on negative emotion processing in euthymic BD-I patients.

Methods

Eighteen euthymic BD-I patients, 7 reporting past traumatic events (T-BD-I), but free of post-traumatic stress disorder (PTSD) symptoms at the moment of the evaluation and 11 never exposed to traumas (NT-BD-I), were compared to 24 not traumatized controls (NC). All participants performed a IAPS-based emotional task: they were required to identify vegetable items (targets) among neutral or negative pictures. Accuracy (percentage of correct responses) and mean reaction times (RT) were recorded.

Results

T-BD-I performed similarly to NC and significantly better than NT-BD-I in terms of accuracy (Fig. 1). No significant between-group effects were observed for mean RT.

Conclusions

A previous history of traumatic events, without current PTSD symptoms, may significantly impact the negative emotion processing in euthymic BD-I. Interestingly, traumatized patients showed a better accuracy when processing both neutral and negative images, thus suggesting that paying more attention to external stimuli may be a successful compensatory mechanism to cope with potential environmental threats.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Novel psychoactive substances in a psychiatric young adults sample: A multicenter, observational study

Introduction

Comorbidities between psychiatric diseases and consumption of traditional substances of abuse are common. Nevertheless, there is no data regarding the use of novel psychoactive substances (NPS) in the psychiatric population.

Objectives

The purpose of this multicentre survey is to investigate the consumption of a wide variety of psychoactive substances in a young psychiatric sample.

Methods

Between September 2013 and November 2015, a questionnaire has been administered, in ten Italian psychiatric care facilities, to a sample of 671 psychiatric patients (48.5% men; 51.5% women), aged between 18 and 26 years (mean age: 22.24).

Results

8.2% of the sample declared use of NPS at least once in a lifetime and 2.2% have assumed NPS in the last three months. The NPS more used were synthetic cannabinoids (4.5%), followed by methamphetamine (3.6%). The three psychiatric diagnosis with more frequent NPS consumption were bipolar disorder (23.1%), personality disorders (11.8%) and schizophrenia and related disorders (11.6%). Bipolar disorder was associated with NPS consumption (P < .001). Among the illicit drugs investigated, 31.4% of the sample was cannabis smoker and 10.7% cocaine user. Moreover, 70.6% of the sample declared alcohol use and 47.7% had binge drinking conducts. In univariate regression analysis, bipolar disorder was positive associated with binge drinking while obsessive compulsive disorder resulted negative associated.

Conclusions

The use of novel psychoactive substances in a young psychiatric population appears to be a frequent phenomenon, probably still underestimated. Bipolar disorder shows an association with NPS use. Therefore, careful and constant monitoring and accurate evaluations of possible clinical effects related to their use are necessary.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Alcohol drinking patterns in young people: A survey-based study

Binge drinking represents a major clinical and public health concern. Here, we investigated the prevalence of binge drinking and its related consequences, in a population of young adults. A questionnaire was administered to a sample of 4275 healthy subjects. In the overall sample, the percentage of binge drinkers was 67.6 per cent; among regular alcohol users, 79.5 per cent reported episodes of binge drinking. Among binge drinkers, several serious consequences were identified (staggering and stuttering, amnesia, loss of control, aggressiveness, sexual disinhibition). Raising awareness about the seriousness of binge drinking may help health care providers to identify cases early on and provide appropriate treatments.

Functional magnetic resonance imaging of internet addiction in young adults

AIM: To report the results of functional magnetic resonance imaging (fMRI) studies pertaining internet addiction disorder (IAD) in young adults.

METHODS: We conducted a systematic review on PubMed, focusing our attention on fMRI studies involving adult IAD patients, free from any comorbid psychiatric condition. The following search words were used, both alone and in combination: fMRI, internet addiction, internet dependence, functional neuroimaging. The search was conducted on April 20^th, 2015 and yielded 58 records. Inclusion criteria were the following: Articles written in English, patients’ age ≥ 18 years, patients affected by IAD, studies providing fMRI results during resting state or cognitive/emotional paradigms. Structural MRI studies, functional imaging techniques other than fMRI, studies involving adolescents, patients with comorbid psychiatric, neurological or medical conditions were excluded. By reading titles and abstracts, we excluded 30 records. By reading the full texts of the 28 remaining articles, we identified 18 papers meeting our inclusion criteria and therefore included in the qualitative synthesis.

RESULTS: We found 18 studies fulfilling our inclusion criteria, 17 of them conducted in Asia, and including a total number of 666 tested subjects. The included studies reported data acquired during resting state or different paradigms, such as cue-reactivity, guessing or cognitive control tasks. The enrolled patients were usually males (95.4%) and very young (21-25 years). The most represented IAD subtype, reported in more than 85% of patients, was the internet gaming disorder, or videogame addiction. In the resting state studies, the more relevant abnormalities were localized in the superior temporal gyrus, limbic, medial frontal and parietal regions. When analyzing the task related fmri studies, we found that less than half of the papers reported behavioral differences between patients and normal controls, but all of them found significant differences in cortical and subcortical brain regions involved in cognitive control and reward processing: Orbitofrontal cortex, insula, anterior and posterior cingulate cortex, temporal and parietal regions, brain stem and caudate nucleus.

CONCLUSION: IAD may seriously affect young adults’ brain functions. It needs to be studied more in depth to provide a clear diagnosis and an adequate treatment.

The Interface between Neuroscience and Neuro-Psychoanalysis: Focus on Brain Connectivity

Over the past 20 years, the advent of advanced techniques has significantly enhanced our knowledge on the brain. Yet, our understanding of the physiological and pathological functioning of the mind is still far from being exhaustive. Both the localizationist and the reductionist neuroscientific approaches to psychiatric disorders have proven to be largely unsatisfactory and are outdated. Accruing evidence suggests that psychoanalysis can engage the neurosciences in a productive and mutually enriching dialogue that may further our understanding of psychiatric disorders. In particular, advances in brain connectivity research have provided evidence supporting the convergence of neuroscientific findings and psychoanalysis and helped characterize the circuitry and mechanisms that underlie higher brain functions. In the present paper we discuss how knowledge on brain connectivity can impact neuropsychoanalysis, with a particular focus on schizophrenia. Brain connectivity studies in schizophrenic patients indicate complex alterations in brain functioning and circuitry, with particular emphasis on the role of cortical midline structures (CMS) and the default mode network (DMN). These networks seem to represent neural correlates of psychodynamic concepts central to the understanding of schizophrenia and of core psychopathological alterations of this disorder (i.e., ego disturbances and impaired primary process thinking).

Adverse Psychiatric Effects Associated with Herbal Weight-Loss Products

Obesity and overeating are among the most prevalent health concerns worldwide and individuals are increasingly using performance and image-enhancing drugs (PIEDs) as an easy and fast way to control their weight. Among these, herbal weight-loss products (HWLPs) often attract users due to their health claims, assumed safety, easy availability, affordable price, extensive marketing, and the perceived lack of need for professional oversight. Reports suggest that certain HWLPs may lead to onset or exacerbation of psychiatric disturbances. Here we review the available evidence on psychiatric adverse effects of HWLPs due to their intrinsic toxicity and potential for interaction with psychiatric medications.

Psyclones: a roller coaster of life? Hidden synthetic cannabinoids and stimulants in apparently harmless products

OBJECTIVE

The urge to gain information on a new drug marketed online as 'Psyclone' has emerged after the death of a 38-year-old man in Bolton (UK). The fatality appeared to be a consequence of smoking this psychoactive product.

METHODS

From October to December 2013, qualitative searches of the Web have been carried out in English and Italian, using the keywords 'Psyclone', 'Psyclone legal high', 'Psyclone incense' and 'Psyclone research chemical' on the Google search engine and on the database provided by the Global Public Health Intelligence Network.

RESULTS

Our research highlighted the existence of two psychoactive products labelled as Psyclone but with different contents and packaging: a herbal blend containing two synthetic cannabinoids (AKB-48 and 5f-PB-22) and a research chemical containing 50% ethylphenidate, 30% caffeine and 20% lidocaine. Desired and side effects of both compounds are explored in the paper.

CONCLUSIONS

Being sold as a legal product, Psyclone may appeal to recreational users, who remain unaware of its real content. This is a serious public health threat, which may lead to acute intoxications and fatalities. Further studies in the field, including Internet monitoring, are therefore required.

Novel psychoactive substances: use and knowledge among adolescents and young adults in urban and rural areas

INTRODUCTION

Novel psychoactive substances (NPS) are new psychotropic drugs, not scheduled under the International Conventions on Psychotropic Substances, but which may pose a relevant public health threat. In this study, we investigated knowledge and use of NPS in a sample of Italian youth in urban and rural areas.

METHODS

Between December 2012 and October 2013, we administered a questionnaire to a sample of 3011 healthy subjects (44.7% men; 55.3% women), aged between 16 and 24 years and recruited in urban, intermediate and rural areas of Italy.

RESULTS

Of the global sample, 53.3% declared to have some knowledge on NPS, with a higher knowledge in urban areas. Mephedrone (26%), desomorphine (22.6%) and methamphetamine (21.7%) were the most commonly known drugs. NPS use was reported by 4.7% of the sample, without significant differences between urban and rural areas; mephedrone (3.3%), synthetic cannabinoids (1.2%) and Salvia divinorum (0.3%) consumption has been identified. NPS use was also predictive of binge-drinking behaviours (χ(2) (4) = 929.58, p < .001).

DISCUSSION

Urban areas may represent a focal point for preventive strategies, given the presence of higher levels of NPS knowledge. Moreover, the association between binge-drinking habits and NPS use was really strong. This issue should not be underestimated because of its medical, psychopathological and social consequences.

The potential of pregabalin in neurology, psychiatry and addiction: a qualitative overview

Pregabalin is an anticonvulsant drug that binds to the α₂δ (alpha2delta) subunit of the voltage-dependent calcium channel in central nervous system (CNS). Pregabalin decreases the release of neurotransmitters, including glutamate, norepinephrine, substance P and calcitonin gene-related peptide. Purpose of this paper is to offer a qualitative overview of the studies currently available in literature about this drug, examining the effectiveness of pregabalin in its various fields of application. Our analysis, conducted on a final selection of 349 scientific papers, shows that pregabalin may help to reduce pain in diabetic neuropathy, in post-herpetic neuralgia and in some patients affected by fibromyalgia. It is also effective for the treatment of diverse types of seizures and has similar efficacy to benzodiazepines and venlafaxine in anxiety disorder. Moreover, pregabalin may be a therapeutic agent for the treatment of alcohol abuse, in both withdrawal phase and relapse prevention. Possible implications in the treatment of benzodiazepines dependence are emerging, but a potential abuse or misuse of the drug has also been reported. Range of dosage may fluctuate considerably, from 75 mg to 600 mg per day. Further studies are needed to completely understand pregabalin mechanism of action in the different diseases.

The endocannabinoid system: a putative role in neurodegenerative diseases

BACKGROUND

Following the characterization of the chemical structure of D9-tetrahydrocannabinol (THC), the main psychoactive constituent of marijuana, researchers have moved on with scientific valuable explorations.

OBJECTIVES

The aim of this review is to highlight the role of endocannabinoid system in neurodegenerative diseases.

MATERIALS AND METHODS

The article is a critical analysis of the most recent data currently present in scientific literature on the subject; a qualitative synthesis of only the most significant articles has been performed.

RESULTS

In central nervous system, endocannabinoids show a neuromodulatory function, often of retrograde type. This way, they play an important role in synaptic plasticity and in cognitive, motor, sensory and affective processes. In addition, in some acute or chronic pathologies of central nervous system, such as neurodegenerative and neuroinflammatory diseases, endocannabinoids can perform a pro-homeostatic and neuroprotective function, through the activation of CB1 and CB2 receptors. Scientific evidence shows that an hypofunction or a dysregulation of the endocannabinoid system may be responsible for some of the symptoms of diseases such as multiple sclerosis, amyotrophic lateral sclerosis, Huntington's, Parkinson's and Alzheimer's diseases.

CONCLUSIONS

The important role played by endocannabinoid system promises interesting developments, in particular to evaluate the effectiveness of new drugs in both psychiatry and neurology.

Prenatal diagnosis of haemophilia B: the Italian experience

This article describes prenatal diagnosis (PND) of haemophilia B (HB) within the framework of Italian haemophilia centres and genetics laboratories. The study details the experience from six haemophilia genetic centres (three in the North, one in the Centre and two in the South of Italy) and summarizes the different techniques used to perform PND of HB during the last 15 years. To date, the Italian HB database includes 373 characterized unrelated patients and their genetic information has permitted the identification of 274 carriers of childbearing age. This database represents the main instrument for timely and precise PND. Sixty-six prenatal diagnoses were performed on 52 HB carriers whose average age at the time was 34 (ranging from 24 to 44 years). In 44 cases, genetic counselling for carrier status determination was performed before pregnancy, while eight were not studied prior to pregnancy. Foetal samples were obtained by chorionic villus sampling in 52 cases, by amniocentesis in 12 while two were diagnosed by analysis of free foetal DNA obtained from maternal peripheral blood. In 35 (53%) pregnancies the foetus was female. For 31 men (47%), haemophilia status was determined by analysis of previously determined informative markers or familial mutations (12 affected and 19 unaffected). There may be more than one laboratory involved in the PND diagnostic pathway (providing DNA extraction, karyotype analysis, gender determination, maternal contamination detection, molecular diagnosis and sequencing). Good communication between all the parties, coordinated by the haemophilia centre, is essential for a successful and rapid process.

Deep intronic variations may cause mild hemophilia A

BACKGROUND

In about 10% of patients with mild hemophilia A, no candidate gene mutations are apparent after complete gene sequencing.

AIM OF THE STUDY

To analyze factor VIII gene (F8) mRNA for mutations in five families with mild hemophilia A with no apparent genomic mutation and a reduced response to desmopressin.

RESULTS

In four cases, mRNA studies revealed the presence of an abnormal mRNA transcript in addition to normal F8 mRNA. Sequencing of the abnormal transcripts revealed complex abnormalities, which allowed the identification of three different intronic variations (c.2113+1152delA, c.5587-93C>T and c.5999-277G>A) at the DNA level, absent from 387 normal alleles. By in silico analysis, c.2113+1152delA and c.5587-93C>T were strongly predicted to result in the generation of new splice sites with the introduction of premature termination codons, while c.5999-277G>A was predicted to generate a new protein with 30 additional amino acids. However, these predictions were not homogeneous across the different mutations and programs used. The detrimental effect of two mutations was also confirmed by in vitro expression studies. These changes were also identified in related female carriers and in other mild HA patients not included in the original study. No mRNA abnormality was identified in the remaining patient.

CONCLUSIONS

Although rare, deep intronic variations may be responsible for mild hemophilia A where no other F8 mutations have been identified and may be associated with a reduced biologic response to desmopressin. F8 mRNA analysis is a useful tool for the identification of deep intronic variation not detectable by standard DNA sequencing.

Familial X;Y translocation with distinct phenotypic consequences: Characterization using FISH and array CGH

X;Y translocation is a relatively rare event in humans. Analyzed cytogenetically, the majority of these aberrations have breakpoints at Xp22 and Yq11. Females with t(X;Y)(p22;q11) are phenotypically normal except for short stature, while the males may have abnormalities. Aberrations that lead to nullisomy of the deleted region and complete loss of the respective genes have been recognized as a cause of variable contiguous gene syndromes in males. The phenotype depends on the extent and position of the deletion showing the variable association of apparently unrelated clinical manifestations such as ichthyosis, chondrodysplasia punctata, hypogonadotropic hypogonadism with anosmia, ocular albinism, short stature, and mental retardation. In addition, some patients have been reported with symptoms of attention deficit hyperactivity disorder. The extent of terminal Xp deletions is limited by the presence of male lethal genes in Xp22.2 at about 10-11 Mb from the telomere. The deletions in the majority of viable reported male patients extend to the STS ( approximately 7.0 Mb) or to the KAL1 ( approximately 8.5 Mb) loci. We present a clinical, cytogenetic, FISH, and array CGH study of a family with an Xp;Yq translocation. The chromosomal status is also discussed in the light of their phenotypic traits. The final karyotypes of the patients were designated as: Patient 1: 46,Y,der(X),t(X;Y)(p22;q12).ish der(X)(Xpter-,DXZ1+,Xqter+)mat.arr cgh Xp22.31p22.33(RP11-60P14 --> RP13-391G2)x0;arr cgh Yq11.221qter (RP11-235I1 --> RP11-270H4)x2.Patient 2: 46,X,der(X),t(X;Y)(p22;q12).ish der(X)(Xpter-,DXZ1+,Xqter+)mat.arr cgh Xp22.31p22.33(RP11-60P14 --> RP13-391G2)x1;arr cgh Yq11.221qter (RP11-235I1 --> RP11-270H4)x1.

Polymorphisms in genes involved in autoimmune disease and the risk of FVIII inhibitor development in Italian patients with haemophilia A

One of the most severe and important complication in the treatment of patients with haemophilia A is the formation of neutralizing antibodies (FVIII inhibitors) that inhibit the clotting activity of substituted FVIII. Both genetic and environmental factors influence the susceptibility of patients to develop inhibitors. The objective of this study was to evaluate whether polymorphisms in different genes involved in the regulation of the immune system may confer susceptibility to inhibitor development in patients with HA. We analysed the distribution of polymorphisms in the CTLA4, PTPN22, IL10, TNFalpha, FOXP3 and IRF5 genes that have been reported to be associated with a number of autoimmune disease. In addition, we evaluated the distribution of IL10 haplotypes in haemophilic patients and healthy controls to assess whether specific polymorphisms in IL10 gene were associated to the risk of inhibitor development. We focused on a cohort of Italian unrelated haemophilic patients with and without a history of inhibitors. Genotyping was carried out with standard methods including RFLP, real time PCR and direct DNA sequencing. Our data show that, considering single nucleotide variations, genotype frequencies in patients with inhibitors were not significantly different from those observed in patients without inhibitors, suggesting a lack of association between these polymorphisms and the development of inhibitors. Moreover, no relationship was found between specific combinations of IL10 alleles and the antibody production. Previous contradictory association studies may depend on the different genetic background of the population examined. Further studies may contribute to a clearer understanding of this process.

Identification of FVIII gene mutations in patients with hemophilia A using new combinatorial sequencing by hybridization

BACKGROUND:

Standard methods of mutation detection are time consuming in Hemophilia A (HA) rendering their application unavailable in some analysis such as prenatal diagnosis.

OBJECTIVES:

To evaluate the feasibility of combinatorial sequencing-by-hybridization (cSBH) as an alternative and reliable tool for mutation detection in FVIII gene.

PATIENTS/METHODS:

We have applied a new method of cSBH that uses two different colors for detection of multiple point mutations in the FVIII gene. The 26 exons encompassing the HA gene were analyzed in 7 newly diagnosed Italian patients and in 19 previously characterized individuals with FVIII deficiency.

RESULTS:

Data show that, when solution-phase TAMRA and QUASAR labeled 5-mer oligonucleotide sets mixed with unlabeled target PCR templates are co-hybridized in the presence of DNA ligase to universal 6-mer oligonucleotide probe-based arrays, a number of mutations can be successfully detected. The technique was reliable also in identifying a mutant FVIII allele in an obligate heterozygote. A novel missense mutation (Leu1843Thr) in exon 16 and three novel neutral polymorphisms are presented with an updated protocol for 2-color cSBH.

CONCLUSIONS:

cSBH is a reliable tool for mutation detection in FVIII gene and may represent a complementary method for the genetic screening of HA patients.

Low protein Z levels and risk of occurrence of deep vein thrombosis

BACKGROUND

Protein Z (PZ) serves as a cofactor for activated factor X inhibition by the PZ-dependent protease inhibitor. In vivo and in vitro studies aimed at investigating the role of PZ levels in venous thombosis have produced conflicting results.

OBJECTIVES

We investigated whether reduced PZ levels and PZ gene common variants are associated deep vein thrombosis (DVT).

PATIENTS AND METHODS

In 197 patients with DVT and in 197 age-matched and sex-matched controls, PZ plasma levels and gene polymorphisms were evaluated by means of an enzyme-linked immunosorbent assay and direct cycle sequence analysis.

RESULTS

Similar PZ levels were found in controls (1.44; SD 0.63 microg mL-1) and in patients (1.44; SD 0.96 microg mL-1). The incidence of PZ levels below the 5.0 (0.52 microg mL-1) or the 2.5 percentile of controls (0.47 microg mL-1) was higher in patients (10.2% and 8.7%, respectively) than in controls {4.1% [odds ratio (OR) 2.7, 95% confidence interval (CI) 1.2-7.3], and 2.0% (OR 4.6, 95% CI 1.5-13.9), respectively}. This relationship was independent of the effect of age, sex, and factor V Leiden and FII A(20210) alleles [OR 2.8 (95% CI 1.1-7.3), and OR 4.9 (95% CI 1.4-17.3)]. PZ levels were associated with the intron C G-42A and the intron F G79A polymorphisms in cases (r2=0.129) and in controls (r2=0.140). However, frequencies of the PZ gene polymorphisms were similar in the two groups and were not associated with very low PZ levels.

CONCLUSIONS

The present data suggest an association between very low PZ plasma levels and the occurrence of DVT, with PZ gene polymorphisms contributing little to this relationship.

Identification of fetal gender in maternal blood is a helpful tool in the prenatal diagnosis of haemophilia

Fetal DNA identification in maternal circulation has provided a new approach for non-invasive prenatal diagnosis. However, fetal DNA can persist in maternal blood long after the delivery, severely hampering this possibility. We addressed the issue of fetal DNA persistence in maternal blood. Thus, we investigated cell-free fetal DNA as a reliable approach in prenatal diagnosis of haemophilia. Forty non-pregnant women, who had had at least a male fetus, 29 control pregnant women, and 14 pregnant women, carriers of hemophilia A or B. The assessment of Y-chromosomal sequences was performed by analysing SRY and amelogenin genes using PCR-based techniques. A protocol consisting of double centrifugation at full speed followed by plasma filtration hampered the detection of Y chromosome-specific sequence in non-pregnant women. In 29 control pregnant women, blinded determination of fetal sex confirmed the specificity and sensitivity of the method applied. In 14 pregnant carriers of hemophilia, the investigation revealed a male fetus in nine pregnancies. Excluding the three cases in which a spontaneous miscarriage occurred, the sensitivity and specificity of fetal sex prediction by SRY and amelogenin gene analyses were both 100% as compared with the invasive approach and the fetal sex outcome at birth (six males and five females). Because of its high accuracy in prediction, fetal gender determination with cell-free fetal DNA in maternal plasma may be a useful tool in prenatal diagnosis of haemophilia allowing for the avoidance of invasive procedures for female fetuses.

A frameshift mutation in the human fibrinogen Aalpha-chain gene (Aalpha(499)Ala frameshift stop) leading to dysfibrinogen San Giovanni Rotondo

We have investigated a 53-yr-old asymptomatic white man with decreased functional, but not immunologic, fibrinogen plasma levels together with prolonged thrombin and reptilase times, detected through routine coagulation studies prior to a surgical procedure. A new heterozygous single nucleotide deletion (C) at position Ala499 within the Aalpha-chain gene was identified, which predicted changes of the corresponding amino acids encoded by the subsequent portion of the exon V and the appearance of a premature stop codon at position 518 (Aalpha[499]Ala frameshift stop). The new dysfunctional fibrinogen, San Giovanni Rotondo variant, was confirmed in vivo by SDS-PAGE analysis of HPLC-purified fibrinogen chains. Mass spectrum examination of the abnormal HPLC-purified peak gave an estimated mass (56,088 Da) similar to that predicted by DNA analysis of the mutated Aalpha-chain gene (56,088 Da) and, after tryptic digestion, the truncated Aalpha-chain was shown only in the propositus, who also carried normal Aalpha-chain. In addition, mass spectrum analysis of the tryptic digest of the abnormal chain confirmed the presence of a new and unpaired cysteine at the last position that was predicted to form a disulfide bridge with human serum albumin. Immuno-blot analysis confirmed that fibrinogen San Giovanni Rotondo variant, but not normal fibrinogen. contained substantial amounts of albumin. Present findings confirm that truncated Aalpha-chain lacking part of the terminal domain may be incorporated into mature fibrinogen molecules and normally secreted in the bloodstream.