Differences In Clinical Status Research Articles

Meta-Analysis of the Effect of Psychotherapy in an Inpatient Setting: Examining the Moderating Role of Diagnosis and Therapeutic Approach

Objective The current meta-analysis investigates the efficacy of psychotherapy during psychiatric hospitalization and examines the moderating role of diagnosis and therapeutic approach. Methods We conducted systematic searches in literature databases, including PubMed, PsycInfo, and Google Scholar. In total, 37 samples were included for the meta-analysis with a total of 4,443 patients. The primary outcome was the standardized mean differences in clinical status measured by symptomatic and functional measures. Results The meta-analysis of 22 samples without a control group resulted in the upper end of the medium effect size for the overall effect of treatment during psychiatric hospitalization that included psychotherapy (k = 22, Cohen’s d = 0.70, and 95% Cl 0.36 to 1.04). The meta-analysis of 15 samples with a control group resulted in the upper end of the low effect size for the contribution of psychotherapy to the improvement of patients’ clinical status measured by symptomatic and functional measures (k = 15, Cohen’s d = 0.43, and 95% CI 0.06 to 0.81). No significant effects were uncovered for psychotherapy orientation. Diagnosis was found to moderate the contribution of psychotherapy in an inpatient setting to the improvement of patients’ clinical condition. Conclusion Psychotherapy during psychiatric hospitalization may be an effective treatment. Across the various samples, psychotherapy has a moderate effect on the reduction of psychiatric symptoms beyond the overall effect of ward treatment.

Untargeted Metagenomic Investigation of the Airway Microbiome of Cystic Fibrosis Patients with Moderate-Severe Lung Disease.

Although the cystic fibrosis (CF) lung microbiota has been characterized in several studies, little is still known about the temporal changes occurring at the whole microbiome level using untargeted metagenomic analysis. The aim of this study was to investigate the taxonomic and functional temporal dynamics of the lower airway microbiome in a cohort of CF patients. Multiple sputum samples were collected over 15 months from 22 patients with advanced lung disease regularly attending three Italian CF Centers, given a total of 79 samples. DNA extracted from samples was subjected to shotgun metagenomic sequencing allowing both strain-level taxonomic profiling and assessment of the functional metagenomic repertoire. High inter-patient taxonomic heterogeneity was found with short-term compositional changes across clinical status. Each patient exhibited distinct sputum microbial communities at the taxonomic level, and strain-specific colonization of both traditional and atypical CF pathogens. A large core set of genes, including antibiotic resistance genes, were shared across patients despite observed differences in clinical status, and consistently detected in the lung microbiome of all subjects independently from known antibiotic exposure. In conclusion, an overall stability in the microbiome-associated genes was found despite taxonomic fluctuations of the communities.

Leg-amplitude differentiation guided by haptic and visual feedback to detect alterations in motor flexibility due to Total Knee Replacement.

Following total knee replacement (TKR), patients often persist in maladaptive motor behavior which they developed before surgery to cope with symptoms of osteoarthritis. An important challenge in physical therapy is to detect, recognize and change such undesired movement behavior. The goal of this study was to measure the differences in clinical status of patients pre-TKR and post-TKR and to investigate if differences in clinical status were accompanied by differences in the patients'' motor flexibility. Eleven TKR participants were measured twice: pre-TKR and post-TKR (twenty weeks after TKR). In order to infer maladaptation, the pre-TKR and post-TKR measurements of the patient group were separately compared to one measurement in a control group of fourteen healthy individuals. Clinical status was measured with the Visual Analogue Scale (VAS) for pain and knee stiffness and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Furthermore, Lower-limb motor flexibility was assessed by means of a treadmill walking task and a leg-amplitude differentiation task (LAD-task) supported by haptic or visual feedback. Motor flexibility was measured by coordination variability (standard deviation (SD) of relative phase between the legs) and temporal variability (sample entropy) of both leg movements. In the TKR-group, the VAS-pain and VAS- stiffness and the subscales of the KOOS significantly decreased after TKR. In treadmill walking, lower-limb motor flexibility did not significantly change after TKR. Between-leg coordination variability was significantly lower post-TKR compared to controls. In the LAD-task, a significant decrease of between-leg coordination variability between pre-TKR and post-TKR was accompanied by a significant increase in temporal variability. Post-TKR-values of lower-limb flexibility approached the values of the control group. The results demonstrate that a clinically relevant change in clinical status, twenty weeks after TKR, is not accompanied by alterations in lower-limb motor flexibility during treadmill walking but is accompanied by changes in motor flexibility towards the level of healthy controls during a LAD-task with visual and haptic feedback. Challenging patients with non-preferred movements such as amplitude differentiation may be a promising tool in clinical assessment of motor flexibility following TKR.

Early clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after anterior cruciate ligament reconstruction.

To determine clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after finalisation of 6months' post-operative rehabilitation following anterior cruciate ligament reconstruction (ACLR). Sixty patients after primary anatomical single-bundle hamstring ACLR were prospectively enrolled. Demographics, subjective, clinical and functional status of the injured knee were recorded at baseline, 6 and 12months post-operatively. Return to pre-injury activities time (months) was monitored. Tensiomyography and isokinetic dynamometry of thigh muscles were performed at 6months, when standard ACLR rehabilitation is finalized. Based on their IKDC Subjective Knee Evaluation scores at 6months, they were assigned into "Normal" or "Sub-normal" group. All the above measured parameters were then compared between the two groups. At 6months' timeline, 21 patients (35%) perceived their knee function as "Normal", while 39 (65%) were "Sub-normal". There were no differences in clinical status between both groups, but patients in Normal group achieved higher IKDC, Lysholm, Tegner scores as well as higher single-leg hop test. They were taller, had lower body mass index and more of them achieved their preinjury level of activity at 12months (67% vs. 33%). Tensiomyography revealed higher biceps femoris as well as semitendinosus and semimembranosus radial displacement values on the operated leg in Normal group. Isokinetic dynamometry showed significantly higher normalised peak torque and average power of knee extensor muscles. Patients who perceive their knee function as normal at 6months following ACLR presented with better neuromuscular properties of the thigh muscles. Decreased hamstring stiffness seems to be the key to higher return-to-preinjury activity. Postoperative rehabilitation should be more focused on reducing hamstring stiffness in addition to improving knee extensor muscle strength. Level of evidence II (prospective cohort study).

FLEXIBLE RINGS IN COMPARISON WITH RIGID RINGS IN THE TREATMENT OF FUNCTIONAL TRICUSPID INSUFFICIENCY: TWO DIFFERENT MODELS OF REVERSE REMODELING OF THE RIGHT HEART

Objective. To compare the models of reverse remodeling of the right heart after the tricuspid valve repair with rigid or flexible rings.Material and Methods. During the period from September, 2016 to February, 2018, 308 patients who had indications for intervention on the mitral valve and concomitant tricuspid insufficiency without significant differences in clinical status were randomized into two groups. Patients of both groups underwent intervention on the mitral valve with concomitant tricuspid valve repair by a rigid ring (Rigid group, n=154) or a flexible ring (Flex group, n=154)Results. The perioperative mortality rates were 2.0% in the Rigid group and 2.5% in the Flex group (p=0.504). There was no difference in the pacemaker implantation rate (5.1% vs. 2.6%, p=0.238). Freedom from tricuspid insufficiency recurrence at 12 months follow-up was comparable (96.7% in the Rigid group vs 96.1% in the Flex group, p=0.521). The global systolic function of the right ventricle (fractional change in area, FAC; ejection fraction, EF) significantly increased in both groups (p<0.001 for both group) without significant intergroup differences (p=0.231 for FAC; p=0.156 for EF). Intergroup comparison of the regional systolic function (systolic excursion tricuspid valve, TAPSE; longitudinal velocity of the tricuspid valve, S’) showed that patients of the Flex group had significantly higher increases in the parameters (p<0.001 for TAPSE; p=0.002 for S’).Conclusion. Both types of the devises had low rates of recurrence of tricuspid insufficiency at the midterm follow-up and contributed to the restoration of the global systolic function of the right ventricle. However, the rigid rings due to their design fix the tricuspid valve annulus, which inevitably affects the regional systolic function. In perspective, the flexible rings can function without interfering with the restoration of the natural shape of the tricuspid valve annulus and its uniform contraction during the cardiac cycle, thus ensuring a significant increase in regional systolic function.

Burr hole trepanation for chronic subdural hematomas: is surgical education safe?

There is a paucity of data concerning the safety and efficacy of surgical education for neurosurgical residents in the evacuation of chronic subdural hematomas (cSDH) by burr hole trepanation. This is a retrospective analysis of prospectively collected data on consecutive patients receiving burr hole trepanation for uni- or bilateral cSDH. Patients operated by a supervised neurosurgery resident (teaching cases) were compared to patients operated by a board-certified faculty neurosurgeon (BCFN; non-teaching cases). The primary endpoint was surgical revision for any reason until the last follow-up. The secondary endpoint was occurrence of any complication until the last follow-up. Clinical status, type of complications, mortality, length of surgery (LOS), and hospitalization (LOH) were tertiary endpoints. A total of n = 253 cases were analyzed, of which n = 217 (85.8%) were teaching and n = 36 (14.2%) non-teaching cases. The study groups were balanced in terms of age, sex, surgical risk (ASA score), and preoperative status (Karnofsky Performance Scale (KPS), modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS)). The cohort was followed for a mean of 242days (standard deviation 302). In multivariate analysis, teaching cases were as likely as non-teaching cases to require revision surgery (OR 0.65, 95% CI 0.27-1.59; p = 0.348) as well as to experience any complication until the last follow-up (OR 0.79, 95% CI 0.37-1.67; p = 0.532). Mean LOS was about 10min longer in teaching cases (53.0 ± 26.1min vs. 43.5 ± 17.8min; p = 0.036), but LOH was similar. There were no group differences in clinical status, mortality and type of complication at discharge, and the last follow-up. Burr hole trepanation for cSDH can be safely performed by supervised neurosurgical residents enrolled in a structured training program, without increasing the risk for revision surgery, perioperative complications, or worse outcome.

Complete percutaneous revascularisation feasibility in ischaemic heart failure is related to improved outcomes: insights from the COMMIT-HF registry.

Heart failure (HF) is a major cause of death in cardiovascular disease. In a post-STICH landscape, we lack data on the role of percutaneous coronary intervention (PCI) in systolic HF patients. Complete revascularisation remains a key unanswered question in ischaemic HF. The COMMIT-HF is an ongoing systolic HF registry (inclusion criteria: HF with left ventricular ejection fraction ≤ 35%, exclusion: acute coronary syndrome). A total of 1798 patients were enrolled. A group of patients with multi-vessel coronary artery disease qualified for PCI were selected and divided into complete (n = 188) and incomplete revascularisation (n = 159) groups. Completeness of revascularisation was defined as successful PCI of every angiographically significant lesion in all arteries with a diameter of ≥ 2 mm without a patent surgical graft. Patients were followed up for a period of at least 12 months with all-cause mortality defined as the primary endpoint. The study groups showed no significant differences in clinical status and echocardiographic parameters, with a lower comorbidity rate in the complete revascularisation group. Procedural characteristics were comparable. There were no significant differences in complication rates. All-cause mortality was significantly lower in the complete revascularisation group after 12-months (6.4% vs. 20.1%, p < 0.001). Multivariate analysis confirmed that achievement of complete revascularisation was an independent factor improving survival (HR 0.39; 95% CI 0.18-0.81, p = 0.01). Percutaneous coronary intervention can be a safe and feasible method of revascularisation in ischaemic HF. Achievement of complete revascularisation with PCI was related to improved outcomes in the analysed patient population.

Immune tolerance induction with multiepitope peptide derived from citrullinated autoantigens attenuates arthritis manifestations in adjuvant arthritis rats.

Citrullinated peptides are major targets of disease-specific autoantibodies in rheumatoid arthritis. Currently, citrullinated peptides are used as biomarkers for diagnosing rheumatoid arthritis by measuring anti-citrullinated protein Ab (ACPA) titers in patients' sera. The accumulation of citrullinated proteins at synovial inflammation sites suggests that they are possible targets for tolerance induction. The objective of the present study was to determine whether citrullinated peptides could induce tolerance in an experimental arthritis model in rats. In view of the multiplicity of target citrullinated autoantigens described for ACPA, we generated a multiepitope citrullinated peptide (Cit-ME), derived from major prevalent citrullinated autoantigens (citrullinated filaggrin, fibrinogen, vimentin, and collagen type II), and studied its effects on arthritic rats. Adjuvant-induced arthritis was induced in Lewis rats. Beginning at day 7 after disease induction, the rats received eight s.c. injections of Cit-ME on alternate days. Differences in clinical status and modulation of T cell populations were analyzed. In adjuvant-induced arthritis rats treated with Cit-ME, disease severity was significantly reduced compared with that of untreated rats. Moreover, amelioration of disease manifestations was related to an increased regulatory T cell subset and an elevated apoptosis rate of T cells associated with reduced Th17 cells. Thus, the use of citrullinated peptides-based immunotherapy may be a promising approach for tolerance induction in experimental arthritis and perhaps even in susceptible individuals that are ACPA-seropositive in human arthritis.

The impact of a cancer diagnosis on weight change: findings from prospective, population-based cohorts in the UK and the US.

BackgroundObesity is a risk factor for cancer incidence and survival, but data on patterns of weight change in cancer survivors are scarce and few stratify by pre-diagnosis weight status. In two population-based cohorts of older adults, we examined weight change in cancer survivors and cancer-free controls in relation to baseline weight status.MethodsIn the English Longitudinal Study of Ageing (ELSA) and the Health and Retirement Study (HRS), we identified participants diagnosed with cancer who had pre- and post-diagnosis BMI data (ELSA n = 264; HRS n = 2553), and cancer-free controls (ELSA n = 1538; HRS n = 4946). Repeated-measures ANOVAs tested three-way interactions by group (cancer/control), time (pre-/post-diagnosis), and pre-diagnosis weight status (normal-weight/overweight/obese).ResultsMean BMI change was -0.07 (SD = 2.22) in cancer survivors vs. +0.14 (SD = 1.11) in cancer-free controls in ELSA, and -0.20 (SD = 2.84) vs. +0.11 (SD = 0.93) respectively in HRS. Three-way interactions were significant in both cohorts (ELSA p = .015; HRS p < .001). In ELSA, mean BMI change in normal-weight cancer survivors was +0.19 (SD = 1.53) compared with -0.33 (SD = 3.04) in obese survivors. In ELSA controls, the respective figures were +0.09 (SD = 0.81) and +0.16 (SD = 1.50). In HRS, mean change in normal-weight cancer survivors was +0.07 (SD = 2.30) compared with -0.72 (SD = 3.53) in obese survivors. In HRS controls, the respective figures were +0.003 (SD = 0.66) and +0.27 (SD = 1.27).ConclusionOver a four-year period, in two cohorts of older adults, cancer survivors lost weight relative to cancer-free controls. However, cancer survivors who were obese pre-diagnosis were more likely to lose weight than healthy-weight survivors or obese adults without a cancer diagnosis. Whether this was due to differences in clinical status or deliberate lifestyle change triggered by the cancer diagnosis is not known. Further research is needed to establish why weight loss occurs more frequently in cancer survivors who were obese at diagnosis, and whether this has favourable effects on mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2407-14-926) contains supplementary material, which is available to authorized users.

010 QUANTIFYING THE ASSOCIATION BETWEEN MORTALITY AND CHANGE IN ACE INHIBITOR AND β-BLOCKER DOSE IN PATIENTS WITH CHRONIC HEART FAILURE: A PROSPECTIVE COHORT STUDY

Background Dose escalation of evidence-based chronic heart failure pharmacotherapy in real-life does not approach that achieved in clinical trials; it is unclear whether this impacts upon mortality. We aimed to quantify the association between temporal changes in β-adrenoceptor antagonist (β-blocker) and ACE inhibitor (ACEI) dose and mortality in patients with chronic heart failure. Methods Prospective observational study of 408 stable chronic heart failure patients with left ventricular systolic dysfunction, managed in a multidisciplinary outpatient clinic, with repeat visit for clinical assessment (mean 354 days after recruitment). The association of between- and within-patient temporal differences in dose of heart failure pharmacotherapies, to all-cause mortality was studied after accounting for collinearity and confounding (including within- and between-patient temporal differences in clinical status). Results During a mean follow-up period of 1060 days, 97 patients (21.6%) died. Between patient analyses revealed increasing dose of ACEI and β-blocker to be associated with reduced mortality, whilst increasing diuretic dose was associated with rising mortality, even after adjustment for confounders. Within patient analyses revealed that upward titration of β-blocker (but not ACEI) was associated with major reductions in mortality, even after accounting for confounders. Temporal changes in diuretic dose, haemodynamic status and renal function were not significantly associated with mortality. Conclusions Sustained between-individual differences in ACEI, β-blocker and diuretic dose are associated with mortality risk after accounting for likely confounders. However, within individuals only escalation of β-blocker dose is associated with improved prognosis.

Clinical Changes in Older Adults During Hospitalization: Responsiveness of the interRAI Acute Care Instrument

To evaluate the responsiveness of the Minimum Data Set interRAI Acute Care (AC), a comprehensive geriatric assessment system, to detect clinical changes in patient status during hospital stays. An explorative secondary data-analysis comparing prospectively collected data with the interRAI AC before hospitalization, upon admission, and at discharge. Clinicians from multiple disciplines in nine geriatric and eight nongeriatric wards of nine acute hospitals performed the assessment. The interRAI AC was administered serially to 256 geriatric inpatients (aged 83.2 ± 5.2; 60% female). Responsiveness (capacity to detect changes in patients) was calculated for the output scales on five domains: activities of daily living (ADLs), cognition, communication, depressive symptoms, and pain. Internal responsiveness was evaluated using the Friedman test and Guyatt technique. Significant differences in clinical status were found for all five domains, based on the Friedman test. Post hoc tests revealed differences between each assessment period, except for cognition and communication from admission to discharge and for depressive symptoms from before admission to discharge. The Guyatt Responsiveness Index showed good to excellent capacity to detect longitudinal changes during hospitalization for cognition, communication, and pain and substantial performance for ADLs and depressive symptoms. In older inpatients, fluctuations in ADLs, cognition, communication, depressive symptoms, and pain can be captured using the interRAI AC output scales, enabling clinicians to evaluate longitudinal changes from admission to discharge and to provide a comparison with patient status before the acute onset of the illness. These results support the use of these scales in geriatric and nongeriatric wards.

The Influence of Social Environmental Factors on Rehospitalization Among Patients Receiving Home Health Care Services

Guided by Orem's theory, this study examined the influence of social environmental factors on rehospitalization among home health care patients. Living arrangement, frequency of caregiving, and type of primary informal care were found to be related to functional ability. Measurable differences in clinical status and functional ability were related to the duration that patients received home health care services until rehospitalization, with the likelihood of rehospitalization increasing proportionately to the magnitude of the differences. Social environmental factors contributed to rehospitalization (self-care deficit) through functional ability (self-care agency) by altering the balance between self-care demand (clinical status) and self-care agency.

P-1224 - Night-time/day-time antioxidant status levels in paranoid schizophrenic inpatients

Introduction The Total Antioxidant State (TAS), expressed as equivalent to the total antioxidant capacity of blood plasma. It is the cumulative ability to trap molecules, as H2O2 and free radicals such as RO, ROO, and O2. Objetives Our aim is to describe the TAS levels in schizophrenic patients and to analyze if this marker has got a circadian rhythm. The only study in humans on this subject has carried out by Benot et al (1999) in healthy subjects, which has reported that there was a circadian rhythm of TAS, with a peak night at 01:00, which correlated directly with melatonin (MLT). Methods The sample was comprised by 43 paranoid schizophrenic inpatients.Blood samples were extracted by venipuncture at 12:00 and 24:00 hours. TAS levels were measured three times: at admission, discharge and three months after discharge. Clinical state was assessed by means of the Clinical Global Impression Scale (CGI). TAS serum levels were measured by ELISA techniques. Results Our results show that there is statistical significance between 12:00 and 24:00 for the TAS at admission and three months control. This means that at both times, the income and control of the three months, the levels of midday TAS is significantly higher than the midnight TAS. However, these differences did not occur at discharge.Respect to CGI there are differences in clinical status, less high-control. TASI 0,66 ± 0,1420,60 ± 0,158,p  TASA 0,64 ± 0,1530,63 ± 0,1350,740. TASC 0,84 ± 0,100,0,76 ± 0,113p  CGI-SI 4,37 ± 0,846,3,05 ± 0,754,3,37 ± 0,720. CGI-GI 3,70 ± 0,640,1,77 ± 0,895,2,23 ± 1,455. Conclusions Our results point to the fact that serum TAS may be considered as a possible marker of psychopathological descompensation worsening.

Oral health care needs and oral health‐related quality of life (OHIP‐14) in homeless people

The aim of this study was (i) to determine the oral health status and oral health care needs of this population, (ii) to assess oral health-related quality of life using OHIP-14 and (iii) to explore whether there is a relationship between oral health status and oral health-related quality of life. A convenience sample was drawn from eight facilities catering for homeless people in south east London. Participants were invited to attend an outreach dental clinic and receive a clinical oral health and treatment needs assessment. The impact of oral disease was assessed using OHIP-14. There were 102 people from a range of vulnerable housing situations invited to participate in the study. The mean age was 39.5 (SD +/- 12.3) and 92% (n = 92) were men. The mean DMFT of dentate participants (n = 94) was 15.5 (SD +/- 7.6), mean DT was 4.2 (SD +/- 5.2), mean MT was 6.8 (SD +/- 6.0) and mean FT was 4.6 (SD +/- 4.8). Normative needs were extensive with 76% having a restorative need, 80% having a need for oral hygiene measures and periodontal treatment and 38% having a prosthetic treatment need. Ninety one per cent of homeless people experienced at least one impact and the mean number of impacts (n = 90) was 5.9 (SD +/- 4.8).The most commonly experienced oral health-related quality of life impacts were in the dimension of pain, with aching in the mouth having a prevalence of 65% and discomfort while eating foods having a prevalence of 62%. Forty-four per cent felt handicapped by their oral condition. The experience of oral impact had only a slight relationship with clinical status and there were no differences in clinical status or oral impact by vulnerability of housing situation. Oral health care needs were extensive and greater than that of the general population in the UK, although disease levels were similar. While homeless people experienced many more oral impacts (as measured with OHIP-14) compared with adults of the same age in the general population in the UK, there was only a slight relationship with clinical status and oral health-related quality of life.

Cardiac magnetic resonance versus routine cardiac catheterization before bidirectional glenn anastomosis in infants with functional single ventricle: a prospective randomized trial.

Routine preoperative catheterization is standard practice in patients with single-ventricle physiology before bidirectional Glenn anastomosis. Because catheterization is invasive and exposes patients to ionizing radiation, cardiac magnetic resonance (CMR) may be a safe and effective alternative. We conducted a prospective, randomized, single-center clinical trial comparing catheterization with CMR in patients considered for bidirectional Glenn operation from February 2003 to June 2006. End points were frequency of adverse events of the preoperative evaluation and a composite score of clinically successful surgery. Of 92 eligible patients, 82 were enrolled on the basis of screening echocardiogram, fulfillment of inclusion criteria, and informed consent. Patients were randomized to catheterization (n=41) or CMR (n=41). There were no baseline differences between groups. Four treatment crossovers occurred, 3 to catheterization and 1 to CMR. Catheter interventions were performed in 17 patients (41%). Catheterization resulted in more minor adverse events (78% versus 5%; P<0.001), longer preoperative hospital stays (median, 2 versus 1 day; P<0.001), and higher hospital charges ($34 477 versus $14 921; P<0.001). There was 1 major adverse event in the CMR group (P=1.0). The operative course and frequency of postoperative complications were similar between the 2 groups. The proportion of patients who had a successful bidirectional Glenn operation was similar (71% versus 83%; P=0.3). At the 3-month follow-up, there were no differences in clinical status, oxygen saturation, or frequency of reinterventions. CMR is a safe, effective, and less costly alternative to routine catheterization in the evaluation of selected patients before bidirectional Glenn operation. Further studies are necessary to determine whether there are long-term benefits from transcatheter interventions in these patients.

Les anomalies structurales observées en imagerie cérébrale dans le trouble bipolaire

The number of structural neuroimaging studies of bipolar disorder have increased during recent years, expanding the literature on the nature of cerebral abnormalities underlying this disorder. The purpose of this paper is to provide a selective review on the main issues concerning this literature. Consistent findings are higher rate of periventricular and deep subcortical white matter hyperintensites seen on MRI. Although there is strong evidence for links between hyper-intense lesions and age or cardio-vascular risk factors, some authors have observed the presence of these abnormalities early in the course of the illness. There are also frequent reports on ventricular enlargement, which has been described as mild and predominant in the right lateral ventricle. Total cerebral volume appears to be preserved. Whereas changes in total grey matter volume are uncertain, evidence suggests that reduced white matter volume reflects genetic factors predisposing to the disorder. Recent studies have reported volume changes in several cortical areas including the subgenual cingular, frontal and temporal cortices. Additionally, a number of reports described morphometric abnormalities in various subcortical structures, such as amygdala, basal ganglia and thalamus. Part of the variability in the morphometric abnormalities might be attributable to differences in clinical status and demographic characteristics of patient groups. Despite some inconsistencies across the studies, it emerges that abnormalities are asymmetrically distributed throughout the two cerebral hemispheres. When increase in volume is reported, it is preferentially localised in the left cerebral hemi-sphere and more specifically in prefrontal and temporal cortices and in amygdala. By contrast, when structural abnormalities concern the right cerebral hemisphere, they are identified as deficits. These latter results are in direct line with those of studies of mania following brain injuries, which report that these secondary mania result mainly from right cerebral lesions. It is also important to notice that most of the abnormalities concern both the cortical and subcortical level, ie frontal, striatal, thalamic and limbic regions. These abnormalities highlight the role in the pathophysiology of bipolar disorder of the loops involved in emotional information processing. The particular role of fronto-limbic loops in the phenomenology of bipolar disorder have been emphasised by recent data from functional neuroimaging studies.

Epidemiology and clinical consequences of vancomycin-resistant enterococci in liver transplant patients.

Vancomycin-resistant enterococci (VRE) are increasingly important as pathogens in liver transplant patients. To guide control efforts, we conducted an epidemiological study of the frequency, source, and modes of transmission of VRE at our center. During September 1998 through August 1999, we obtained weekly surveillance cultures from consenting liver transplant patients and surfaces in their rooms. Pooled handwash specimens from personnel also were obtained. Specimens were processed on selective media to detect VRE, and isolates were typed by pulsed field gel electrophoresis. Information was collected from patient records concerning in-hospital treatment and clinical course. Serial cultures were obtained during 33 admissions of 29 patients. VRE were detected in initial specimens from 6 admissions, and nosocomial acquisition of VRE occurred in 12 (44%) of the remaining 27 admissions. Seven different strain types of VRE were detected. The initial site of acquisition was stool in all cases; bile became culture-positive in only two patients. Overall, 16 (55%) of the 29 patients became colonized, usually after transplantation. VRE were detected in environmental cultures during 10 admissions and in 2 of 21 pooled handwashes. No statistically significant differences in clinical status or treatment were found when colonized patients were compared to noncolonized controls. The only VRE infection resulted from a choledochojejunostomy anastomotic leak. Alimentary tract colonization by VRE occurred commonly in liver transplant patients, probably by cross-transmission. The clinical consequences were modest in the patients studied, but colonized transplant patients provide a substantial reservoir for continued VRE transmission in hospitals.

Attitude profiles and clinical status in patients with chronic pain

While attitudes toward pain have been identified as important mediators of patient adjustment to pain and response to treatment, research to date has focused on single attitude scales. The present study examined relations between attitude profiles and a set of variables reflecting clinical status in 395 chronic pain patients seen through a comprehensive pain center. A clustering procedure identified four distinct patient clusters, two of which displayed self-reliant attitude sets and two of which displayed medically oriented attitudes. Within each of the latter groupings, one patient cluster demonstrated attitudes that reflected little emotionality associated with pain, while the attitudes of the other cluster reflected higher levels of emotional involvement. Clusters differed on clinical status variables, with the self-reliant/emotional and self-reliant/low emotional groups reporting less severe pain, less disability, less emotional distress, and a greater likelihood of employment than the medically oriented groups. The medically oriented groups differed in terms of level of distress, with the more distressed group reporting pain of a greater duration. The results suggest that patients can be classified into attitudes profiles that are associated with meaningful differences in clinical status. Further research should investigate attitudes among more functional patients with chronic pain, especially as they affect the evolution of chronic pain syndromes.

Differences in Chemokine Coreceptor Usage between Genetic Subtypes of HIV-1

HIV-1 uses chemokine coreceptors for cell entry. CXCR4 is the major coreceptor for T-cell-line-adapted isolates and CCR5 for non-T-cell-line-adapted isolates. This study investigated if coreceptor usage differs between genetic subtypes of HIV-1. Eighty-one primary isolates representing nine different genetic subtypes (A–J, except I) were tested on U87.CD4 glioma cells stably expressing chemokine receptor CCR1, CCR2b, CCR3, CCR5, or CXCR4. Coreceptor usage was compared to biological phenotype of the isolates (rapid/high, syncytium-inducing or slow/low, non-syncytium-inducing) and to clinical and immunological status of the study subjects. CXCR4 usage was perfectly correlated to the biological phenotype for all subtypes; all of 26 isolates with rapid/high phenotype and none of 55 isolates with slow/low phenotype could infect the CXCR4 expressing cell line. Importantly, the CXCR4-positive, rapid/high phenotype was underrepresented among subtype C isolates. Furthermore, dual tropism for CXCR4 and CCR5 was not found among subtype D isolates. Uni- and multivariate analyses indicated that these subtype-specific differences in coreceptor usage were not due to differences in clinical status, CD4 counts, or treatment. This study shows that CXCR4 usage determines the biological phenotype for all subtypes, but that there appear to exist subtype-dependent differences in frequency of usage of certain coreceptors. This opens up the possibility that genetic subtypes may differ in important biological properties such as virulence, tissue tropism, and transmissibility.

Increased waiting time for liver transplantation results in higher mortality.

Waiting time to liver transplantation (LTx) has dramatically lengthened, but the proportion of candidates who die awaiting transplantation has not increased. We evaluated whether longer waiting time for LTx candidates increases mortality. A cohort of candidates listed for LTx between 1990 and 1993 by three large transplantation programs was followed for 2 years. The exposure measure was ABO blood type, which is not inherently related to outcome, but is a major determinant of waiting time. The main outcome measure was 2-year mortality, as evaluated by logistic regression analysis that controlled for differences in clinical status at the time of evaluation for LTx. The 308 candidates with type O blood waited longer for LTx (median 109 days) than the 399 candidates with other blood types (median 58 days) (P=0.001). Candidates listed for LTx with type O blood had better clinical status at evaluation, but then had higher pretransplantation mortality (13.3%) than other candidates (7.0%) (P=0.005). Blood group O candidates had higher 2-year mortality (26.6%) than other candidates (22.1%), which on multivariate analysis resulted in a mortality odds ratio at 2 years of 1.52 (95% confidence interval=1.04-2.23). With the difference in median waiting time between blood groups increasing from 44 days in the first year to 108 days in the third year, the 2-year mortality odds ratio also rose from 0.94 to 1.97. When compared with LTx candidates with other blood types, blood type O candidates have longer waiting times and higher pretransplantation mortality, which results in higher 2-year mortality.