Partial Remission Of Symptoms Research Articles

"I Was Almost in Disbelief" - Qualitative Analysis of Experiences and Expectations Among Psoriasis Patients Undergoing Biologic Treatment with Secukinumab.

Psoriasis is a highly debilitating chronic inflammatory disease. Increased understanding of its pathophysiology has enabled development of targeted treatments such as biologics. Several medical treatments have been shown to be influenced by patients' experiences and expectations. However, only little is known about patients' experiences with and expectations towards biologics. Our objectives were to identify patients' treatment experiences and treatment expectations and assess their trajectories over the course of treatment with the IL-17A inhibitor secukinumab. Moreover, we aimed to document effects of psoriasis, factors that influence symptomatology, and prior treatment experiences. We conducted semi-structured interviews with n = 24 patients with moderate-to-severe plaque psoriasis and employed a qualitative content analysis to derive thematic and evaluative codes. Findings were validated via peer debriefings with experienced dermatologists. Patients reported burdensome physical and psychological psoriasis symptoms and identified factors that can improve or worsen symptomatology, including stress and self-efficacy. Prior treatment experiences were mostly negative. Past barriers to effective treatment included time constraints or limited access. Concerning secukinumab, patients initially expected complete to partial remission of symptoms and occurrence or absence of side effects. Closer inspection of expectations and experiences revealed three trajectories. For most patients, initial expectations were met and future expectations remained unchanged. For the other patients, however, the experience did not match their initial expectation. One group then adapted their future expectations according to their experience, while the other group did not. To our knowledge, this is the first qualitative study to assess expectations towards treatment effectiveness and side effects, their trajectories, and interplay with experiences among psoriasis patients. Our findings highlight the value of further research on the subject in order to optimize care for psoriasis patients and to learn more about the trajectories and influence of treatment expectations in general.

Risperidone and fluvoxamine; two directions of augmentation: a case report

IntroductionOnly 40%–70% of patients have an adequate response to the first-line treatment of OCD with SSRIs. Antipsychotic augmentation is effective in the management of both obsessions and compulsions and these drugs are currently the first-line pharmacological augmenting agents for OCD. (Jaisoorya T, Thamby A. Antipsychotic augmentation in the treatment of obsessive-compulsive disorder. Indian Journal of Psychiatry. 2019;61(7):51)ObjectivesWe present the cases of a 31-year-old man and a 21- year-old girl. A 31 -year old man experienced hygienic obsessive and compulsive symptoms with excessive showering for one year (YBCOS 20). First, he was treated with 100 mg of fluvoxamine daily which helped him gain partial remission of symptoms. After a stressful period at work and his showering compulsions got worse. Our female patient suffered from compulsive hand washing and disinfection with fear of getting contaminated by other people (YBCOS 24). She was also treated for anorexia nervosa. At the moment of referral to our outpatient clinic, she had already been taking 2 mg of risperidone daily, but still, her compulsions persisted.MethodsBoth patients were included in outpatient service treatment. They were followed up weekly, psychotherapeutically supported and their psychopharmacotherapy was titrated. In the case of our male patient, risperidone of 1 mg/day was added to the ongoing fluvoxamine of 100 mg/day. Our female patient was given fluvoxamine 50 mg/a day and gradually increased to 100 mg/day with an ongoing 2 mg/day of risperidone.ResultsAfter two weeks, the hygiene compulsions of the 31-year-old-man completely remitted (YBCOS 6). He stopped excessive showering and became fully functional at work and in family relations. Our female patient also continued to take risperidone in augmentation with fluvoxamine as recommended. Her compulsions improved, and she returned to her hobbies and her college lectures (YBCOS 8). They have both been advised to continue outpatient psychiatric treatment and to regularly use pharmacotherapy.ConclusionsThe condition of both of our patients improved after adding an augmentative agent to the therapy. In the first case, it was risperidone as a fluvoxamine augmentation, and in the second, fluvoxamine was added as a risperidone augmentation. The combination of these two drugs, rather than each other being used on its own, proved to be a powerful therapeutic tool in the treatment of OCD. Further clinical studies are required for a better understanding of the underlying neurobiological mechanism of this effective combination.Disclosure of InterestNone Declared

Influence of COVID-19 in the development of delusional ideas disorder. A case report

IntroductionHypochondria is characterized by the presence, for 6 months or more, of a generalized and non-delusional concern with fear of having (or the idea that one has) a serious illness, based on the wrong interpretation of the symptoms. In somatic-type delusional disorder, the delusional idea is fixed, indisputable, and occurs intensely because the patient is fully convinced of the physical nature of the disorder.Objectives To describe a clinical case and make a differential diagnosis of hypochondriac disorder vs somatic-type delusional disorder.MethodsCase report: 61-year-old woman, after suffering from COVID-19, develops a hypochondriacal disorder vs. somatic delusional disorder, presenting anxiety-depressive symptoms and digestive somatic complaints, with a loss of 15 kg of weight. She made frequent visits to doctors and multiple complementary tests discarding organicity. She required involuntary hospital admission for 48 days, and pharmacological treatment with Venlafaxine 150 mg, Olanzapine 5mg, Mirtazapine 30mg and Alprazolam 1mg. The patient presented slow evolution during admission, with ups and downs and stagnation, meriting enteral nutrition due to refusal to ingest, given abdominal kinesthetic hallucinations and digestive evaluation (EDS) with a result of antral gastritis and negative H. pylori. In subsequent follow-ups after partial remission of symptoms, obsessive personality traits are glimpsed, although with better personal functioning.ResultsThe diagnosis at discharge was inconclusive, however the data points to a somatic-type delusional disorder.ConclusionsThe influence of COVID-19 as a triggering factor, social isolation and premorbid personality traits, influence the development of a Somatic Delusional Disorder vs Hypochondriac Disorder, regarding this case.DisclosureNo significant relationships.

Omalizumab: for severe ocular allergy

Identify the efficacy of Omalizumab in severe atopic and vernal ketatoconjunctivitis (AKC e VKC). Four pediatric patients with severe refractory allergic keratoconjunctivits were selected and received Omalizumab 300mg once a month for at least 6 months. Ocular symptoms need for medication and use of topical steroids were analyzed before and after the treatment. −Patient 1: Severe AKC, IgE of > 2000 UI/mL and skin prick test for Dermatophagoides pteronyssinus(Dp) 7x7mm wheal. Improve of pruritus and conjunctival hyperemia after the first dose of Omalizumab; however, after the 2nd dose there was worsening of the pruritus and increased ocular secretion. After the 6thdose the drug was discontinued for treatment failure.−Patient 2: Had increase intraocular pressure due to chronic use of topical steroids; IgE of 488UI/mL and no sensitization to any aeroallergns. The VKC symptoms of pruritus, lacrimation, photophobia and conjuctival hyperemia improved after the first dose, and he remained asymptomatic thereafter up to one year.−Patient 3: Showed significant improvement of symptoms and resolution of corneal ulcers. After 3-month ocular symptoms of AKC returned. The treatment was discontinued after 6 months. Serum IgE of 996 UI/mL and 8x8mm wheal in skin prick test for Dp.−Patient 4: Showed no improvement of AKC after 6 doses of Omalizumab 300mg, and after 6 months, the treatment was discontinued. Serum IgE 171 UI/mL and skin prick test positive for Dp (8x8mm) and Blomia(4x4mm). Omalizumab should be tried as a therapy for severe and refractory conjunctivitis. Of the 4 patients evaluated, one VKC presented complete response to the treatment, two had partial remission of symptoms, and one AKC did not remit with omalizumab. The best patient profile and treatment regimen are yet to be determined. Controlled studies are needed in the future.

Empirically defining treatment response and remission in body dysmorphic disorder.

The number of clinical trials in body dysmorphic disorder (BDD) has steadily increased in recent years. As the number of studies grows, it is important to define the most empirically useful definitions for response and remission in order to enhance field-wide consistency and comparisons of treatment outcomes across studies. In this study, we aim to operationally define treatment response and remission in BDD. We pooled data from three randomized controlled trials of cognitive-behavior therapy (CBT) for BDD (combined n = 153) conducted at four academic sites in Sweden, the USA, and England. Using signal detection methods, we examined the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) score that most reliably identified patients who responded to CBT and those who achieved remission from BDD symptoms at the end of treatment. A BDD-YBOCS reduction ⩾30% was most predictive of treatment response as defined by the Clinical Global Impression (CGI) - Improvement scale (sensitivity 0.89, specificity 0.91, 91% correctly classified). At post-treatment, a BDD-YBOCS score ⩽16 was the best predictor of full or partial symptom remission (sensitivity 0.85, specificity 0.99, 97% correctly classified), defined by the CGI - Severity scale. Based on these results, we propose conceptual and operational definitions of response and full or partial remission in BDD. A consensus regarding these constructs will improve the interpretation and comparison of future clinical trials, as well as improve communication among researchers, clinicians, and patients. Further research is needed, especially regarding definitions of full remission, recovery, and relapse.

Treatment effects and comorbid diseases in 58 patients with visual snow

ObjectiveTo evaluate pharmacologic treatment options for visual snow and to report prevalence of comorbid diseases.MethodsMedical charts of patients with a diagnosis of visual snow at the neurology outpatient clinic were reviewed on prescribed medication, and comorbid migraine, tinnitus, and psychiatric conditions including depression and anxiety.ResultsFrom 2007 to 2018, 58 patients were diagnosed with visual snow. Comorbid migraine was present in 51.7% of patients, lifetime depression in 41.4%, and lifetime anxiety in 44.8%. Lamotrigine was prescribed most frequently (26/58) and resulted in partial remission of symptoms in 5/26 (19.2%). No patients reported complete remission. Adverse events occurred in 13/26 (50.0%) patients. None of the other prescribed drugs (valproate [n = 7], topiramate [n = 4], acetazolamide [n = 2], flunarizine [n = 1]) led to improvement except for topiramate in one patient, who discontinued, however, because of adverse events.ConclusionsOf medication prescribed (lamotrigine, valproate, acetazolamide, flunarizine), only lamotrigine afforded some improvement in a small minority of patients. Migraine, depression, anxiety, and tinnitus were common comorbid diseases.Classification of evidenceThis study provides Class IV evidence that for some patients with visual snow, lamotrigine resulted in partial remission of symptoms.

Revision of Sleeve Gastrectomy with Hiatal Repair with Gastropexy for Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is the major drawback of laparoscopic sleeve gastrectomy (LSG). Conversion to Roux-en-Y bypass is recommended but might not be suitable for all patients. We retrospectively reviewed the data of patients who underwent laparoscopic hiatal repair and gastropexy for intractable GERD after LSG between 2015 and 2017. Data on upper gastrointestinal (GI) study findings and proton pump inhibitor (PPI) use was collected. The GERD-health-related quality of life (GERD-HRQL) questionnaire assessed patient symptoms. Perioperative outcomes, GERD symptoms, and medication details were analyzed. Twenty-eight patients were included. Mean interval from the initial LSG to revision surgery was 40.8months (range, 6-108). Mean body mass index before LSG was 34kg/m2, whereas that before revision surgery was 25.7kg/m2. Mean revision surgery time was 126min, whereas the mean length of stay was 3.6days. No major surgical complication occurred. The mean GERD-HRQL score before revision surgery was 24.3 and decreased to 12.3 at 1month after surgery. Mean GERD-HRQL scores at 6, 12, and 24months after revision surgery were 16.8, 17.4, and 18.9, respectively. All patients required daily proton pump inhibitor pre-operatively; only 26% could discontinue them postoperatively. Of the 28 patients, 14 (50.0%) were satisfied with the surgery, 8 (28.6%) had a neutral attitude, and 6 (21.4%) were dissatisfied. Three (11.1%) patients agreed to undergo Roux-en-Y gastric bypass. Hiatal repair with gastropexy is an acceptable treatment option for GERD after LSG but not very effective because of partial remission of symptoms.

Treatment strategy of allergic rhinitis in the face of modern world threats.

Allergic rhinitis (AR) is the most common form of allergy, which - as epidemiological research has shown - applies to nearly 25% of the population. AR significantly affects the quality of life of the patient, and the more severe the disease, the greater the risk of developing bronchial asthma. One of the factors affecting the severity of symptoms and the degree of their control is air pollution. In some patients, despite proper treatment, persistence or only partial remission of symptoms (uncontrolled allergic rhinitis) is observed. This can lead to an increase in comorbidities - inflammation of the paranasal sinuses, otitis media and asthma - both in children and in adults. The treatment of allergic rhinitis, in accordance with the standards, consists in: education of the patient, elimination of the allergen from the environment and factors intensifying the course of the disease, selection of proper pharmacotherapy and specific allergen immunotherapy. Many factors influence the selection of the antihistamine used, e.g., the opportunity of safe increase of the dosage.

Neurocognitive and Symptom Trajectories of ADHD from Childhood to Early Adolescence.

This longitudinal study investigated changes in neurocognitive functioning from childhood to early adolescence in a sample of children diagnosed with DSM-IV attention-deficit hyperactivity disorder (ADHD). It also compared the neurocognitive trajectories of children who continued to meet the diagnostic criteria for ADHD at follow-up and those in partial remission. Children diagnosed with ADHD (N = 55) were tested at baseline (M = 7.7 years, SD = 1.5) and 4 years later (M = 11.7 years, SD = 1.5) on measures of intellectual, academic, and executive functioning. Group and individual analyses were used to examine neurocognitive functioning over this period. Intellectual function was stable over the 4-year interval. Reliable change analyses highlighted variability in academic performance. Approximately half the sample showed a reliable decline in at least 1 academic subject with almost a third showing reliable improvement. Executive functions generally followed a stable or improving course, with significant improvements on measures of information processing, attentional control, cognitive flexibility, and goal setting. There was some evidence of better neurocognitive performance in those with partial symptom remission at follow-up. Study findings emphasize the importance of monitoring academic performance in children with ADHD, including examination of change at the individual level. Declines in academic performance were observed, despite stable intellectual and improving executive function. Early cognitive functioning did not predict symptom remission; however, reduced symptoms at follow-up were associated with better executive function.

Psychopathology of depersonalization and de-realization. What is the limit between normal and pathological?

A 21-year-old woman, distance-learning psychologist with a history of parent violence during her early childhood in the context of her father's alcohol poisoning, describes experiences of depersonalization and de-realization, of which she is aware since the age of five years, in situations of stress or out, for example, when looking in the mirror or even playing. She consulted to psychiatry, seven months after his father died of lung cancer, he frequently smoked tobacco and cannabis at home, had been diagnosed a year before his death. The patient described increased anxiety symptoms, with panic attacks, hypnopompic and hypnagogic hallucinations, and increased depersonalization and de-realization phenomena. She denies the use of psychoactive substances in addition to tobacco and alcohol, occasionally. Likewise, the depressive symptomatology was objectified in relation to the grief for the loss of his father. She received treatment with SSRIs and two months later, referred partial remission of symptoms, with persistence of dissociative symptoms. In addition, she presents emotional instability, feelings of emptiness, self-defeating ideas without structured suicide ideation. In recent months, he has presented avoidant behaviors and isolation with affectation in his habitual functioning. Now, in this case: are depersonalization and de-realization normal, part of the anxiety crisis, a sign of a high-risk mental state, or a prelude to a serious mental illness?Disclosure of interestThe author has not supplied his/her declaration of competing interest.

The experience of transitioning from relapsing remitting to secondary progressive multiple sclerosis: views of patients and health professionals

Purpose:The majority of people with multiple sclerosis (pwMS) initially present with discreet periods of relapses followed by partial remission of symptoms (RRMS). Over time, most pwMS transition to secondary progressive MS (SPMS), characterized by a gradual accumulation of disability. This study aimed to explore the experiences, coping and needs associated with transitioning from RRMS to SPMS.Method: Data were collected via semi-structured interviews with nine pwMS and seven specialist MS health professionals (HPs). Thematic analysis was used to analyze the data.Results:Four major themes were identified: “Is this really happening?”; “Becoming a reality”; “A life of struggle”; and “Brushing oneself off and moving on.” Findings suggested a process of moving from uncertainty towards confirmation of one’s diagnostic label. Being reclassified with SPMS served as a turning point for many, and was accompanied by a range of cognitive, emotional and behavioral responses. The value of adequate information and support surrounding the transition, and the potential benefit of education and support for health professionals in relation to the transition were indicated.Conclusions: Understanding pwMS’ experiences of the transition is essential if clinicians are to provide pwMS with appropriate support during the transition.Implications for RehabilitationThe timing and delivery of preparatory education for patients about the transition to SPMS should be carefully considered.Sufficient information and follow-up support following the reclassification of SPMS is crucial but sometimes lacking.The importance of sensitive communication of the reclassification of SPMS was highlighted. MS Specialist health professionals may potentially benefit from training and support around communication of the reclassification of SPMS.Given the potential negative psychological impact of the transition, the psychological wellbeing of the patients during the transition to SPMS should be monitored and responded to appropriately.

Without awareness of what I am

Introduction Fifty-year-old male. As a summary note that has a history of psychotic disorder from 25 years to coincide with the theological studies and your income as a priest. It has continued since then reviews and consultations in psychiatry, with two previous hospitalizations in private hospitals. It was stable with low doses of risperidone. Apparently, it makes a routine life linked to the activities of the church. Two months ago, he began to be irritable, suspicious, with discussions and problems at work, coinciding with the abandonment of treatment. Since the death of her mother a year ago has presented worsening. Objectives It presents the case of a patient who has no awareness of illness. Methods Psychopathological examination: conscious, oriented, scarcely manageable. Psychomotor restlessness. Expansive while maintaining distances, dysphoric and irritable. Verbiage. Ideas prejudice family-centered. There appears to be perceptual disturbances. Sleep-wake rhythms preserved. Results Treatment was initiated with injectable paliperidone administered dose of 150mg and 100mg, with 12mg of oral paliperidone with good response progressively. At high partial remission of symptoms, it is factual. Conclusions The lack of awareness of the disease is non-pharmacological factors that can make it difficult to comply with neuroleptic treatment. These patients do not calibrate well how important that medication has on the evolution of his illness. Therefore, the therapeutic substance of such failure worsens the quality of life of patients and their families, as well as the prognosis of their disease presenting increasingly severe relapses.

Cell therapy effects portrayed on positron emission tomography of the brain serve as a new dimension for autism

Cell therapy offers a promising premise in alleviating complex neurological disorders. Autologous bone marrow mononuclear cells (BMMNCs) have been used in many studies and have been documented to have a safe and ethical profile. These cells have shown angiogenetic and immunomodulatory properties in addition to other neuroprotective effects. Precisely, these may serve to address a disorder at a neurophysiological level and thus, hold gratifying results in autism. The literature suggests hypoperfusion and immune alteration as major underlying pathogenetic mechanisms in autism. Herewith, we present a case of autism treated with intrathecal administration of autologous BMMNCs. Results were documented objectively on Indian Scale for Assessment of Autism (ISAA), Childhood Autism Rating Scale (CARS), Clinical Global Impression (CGI) scores and positron emission tomography computerized tomography (PET-CT) scan. On regular follow-up assessment of the patient at 3 mo, at 6 mo (pre 2nd dose) and at 9 mo (i.e., 3 mo post 2nd dose), significant clinical improvement was noted in social relationship, communication and behavior. On the outcome measure, his ISAA score improved from 132 (moderate autism) to 103 (mild autism). On comparison of the PET-CT scan, changes in metabolism correlated with the clinical improvements. On the CGI scores, he showed improvement in all the three domains, with a decrease in the severity of illness and with partial remission of symptoms. This case provides a useful insight into the clinical effects of autologous BMMNCs in autism and guides us to plan future studies and offers a promising premise in alleviating complex neurological disorders.

Cognitive dysfunction in major depressive disorder: effects on psychosocial functioning and implications for treatment.

Major depressive disorder is a common condition with a high rate of recurrence, chronicity, and staggering economic burden, including disability in the workforce.1 In 2010, MDD was the second leading medical cause of burden globally, with highest estimates of disability in people of working age.2 In Canada, the annual prevalence of MDD is 3% to 4% overall, and 79% of people with MDD report some interference with work functioning, either decreased work productivity and (or) absenteeism.1 In addition to work impairment, the psychosocial impact of MDD often affects a person’s level of functioning in family and social relationships. While there is clearly an association between improvement in depressive symptoms and functioning, symptom improvement can also be dissociated from functional improvement and work loss.3,4 Hence there has been increasing recognition that symptomatic remission is an insufficient goal of treatment for MDD and that return to premorbid psychosocial functioning should be targeted.5 Cognitive dysfunction refers to deficits in attention, verbal and nonverbal learning, short-term and working memory, visual and auditory processing, problem solving, processing speed, and motor functioning. Cognitive dysfunction may be a primary mediator of functional impairment in MDD.6 Cognitive complaints are core symptoms of acute MDEs, and diminished ability to think or concentrate and (or) indecisiveness are criterion items for the diagnosis of MDD. Several other core symptoms of MDD may act as mediators of cognitive dysfunction, including psychomotor retardation, amotivation, fatigue, insomnia, and mood disturbances. Deficits on neuropsychological testing are well demonstrated in people with MDD, compared with healthy subjects, with many studies and meta-analyses showing moderate effect sizes in neurocognitive domains of processing speed, attention, executive function, learning, and memory7,8 as well as in cognitive affective bias. Cognitive affective bias reflects distorted information processing and (or) focus moving away from positive stimuli and toward negative stimuli,7 and abnormal responses to negative feedback and decision making.9 It is also apparent that, while cognitive dysfunction in MDD may improve with treatment and resolution of depressive symptoms, cognitive deficits can still be detected even in periods of symptom remission. In a 3-year, follow-up study of patients with MDD, the proportion of time with cognitive complaints was reported as 94% during acute depressive episodes; this remained at 44% despite full or partial symptom remission during treatment.10 Cognitive performance on tests of immediate memory, attention,11 and processing speed12 was reported to be inferior in patients with MDD who met criteria for remission, compared with healthy subjects. Meta-analyses show that cognitive deficits in executive function are still present in remitted patients,13,14 which may explain persistent psychosocial impairment in remission. While it is beyond the scope of our paper to review the underlying pathophysiology, recent evidence points to neural mechanisms that also support a neurocognitive model of depression.15 Overall, cognitive dysfunction, work, and psychosocial limitations are prevalent in patients with current and remitted depression.10 Therefore, we hypothesize that cognitive dysfunction may be a major mediator of psychosocial limitations in patients with MDD. We aimed to review recent evidence that cognitive dysfunction is a mediator of functional disability in MDD, and that pharmacotherapy and psychotherapy specifically target the cognitive domain. We conducted a PubMed literature search for the period from January 2000 up to January 2014 to identify relevant studies (search strategy available on request) for this review.

Steroid-Sparing Effect of Extracorporeal Photopheresis in the Therapy of Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation

IntroductionSteroid-refractory graft-versus-host disease (GVHD) remains a challenging therapeutic problem after allogeneic hematopoietic stem cell transplantation (HSCT). The aim of this study was to evaluate the clinical effect of extracorporeal photopheresis (ECP), and its impact on intensivity of immunosuppresive therapy in allogeneic HSCT patients. Patients and MethodsIn this study 443 Therakos ECP procedures were performed in 21 patients after allogeneic HSCT with acute (aGVHD, 8 patients) or chronic (cGVHD, 13 patients) therapy-refractory GVHD. The median age at ECP onset was 20.5 years (range, 10–55). Venous access was provided by a nontunelized central venous catheter (12 patients) or 9.6-French portacath (9 patients). ResultsIn the cGVHD group 9/13 patients were improved with a 4-year overall survival rate of 67.7%. ECP led to steroid discontinuation in 6 and substantial dose reduction in 5 patients. The prednisone dose equivalent per kilogram body weight decreased from 0.32 mg to 0.07 mg after therapy. Therapy of aGVHD led to complete or partial symptom remission in 3/9 subjects. The change in steroid dose in the aGVHD group was not significant, there were no long-term survivors. Portacath access was well tolerated and provided adequate blood flow rates. ConclusionsThe ECP therapy significantly reduced the rates of remissions with steroid discontinuation among cGVHD but not aGVHD patients. Rare ECP-related complications were either catheter related or anticoagulation induced during ECP procedures. Photopheresis was a safe, effective method to treat steroid-resistant cGVHD.

Intra-Articular Ultrasound-Guided Injection of Sinovial® Forte 1.6% in Patients Affected by Symptomatic Hip Osteoarthritis: Effectiveness and Safety in a Large Cohort of Patients

The aim of this prospective observational study is to assess the efficacy and safety profile of intraarticular Sinovial® Forte 1.6% administered under ultrasound-guidance in a large cohort of patients affected by symptomatic hip osteoarthritis (OA). Patients with symptomatic hip OA referred to our clinic in 2008–2010 received one 4 ml (2 vials) intra-articular injection of Sinovial® Forte 1.6% under ultrasound guidance. Patients were followed-up every 3 months for a total of 6 months and were offered an optional, additional injection at the 3-month follow-up visit if clinically justified. At each visit, pain scores [0–10 Visual Analogue Scale (pain VAS)], Lequesne index scores and NSAID intake were recorded. Adverse events (AEs) were recorded throughout the study. An effect size of 30% and 50% reduction in Lequesne index and Pain VAS scores was evaluated for each patient to ascertain the number of patients achieving partial remission of symptoms and functional impairment by the use of intra-articular hyaluronic acid in hip osteoarthritis. One hundred and fourteen patients completed the 6-month follow-up and received a total of 142 injections. A statistically significant reduction in Lequesne index scores, VAS pain scores and NSAID consumption was observed at all time-points ( p < 0.05). No systemic, severe or even moderate side effects were observed. Only 7 patients reported mild local reaction at the injection site, consisting of mild pain and localized warmth, which resolved spontaneously without any additional medication. This study provides evidence of the efficacy and tolerability of Sinovial® Forte 1.6% in the treatment of patients affected by symptomatic hip OA. Sinovial® Forte may also offer economical benefits, owing to the reduction in NSAID consumption associated with this treatment. The percentage of patients achieving the effect size of 30% and 50% reduction in Lequesne index and pain VAS scores encourages the use of intra-articular hyaluronic acid in patients with hip osteoarthritis.

Attention deficit hyperactivity disorder and critical incidents in a Scottish prison population

There is a well-documented association between ADHD symptoms and antisocial behaviour. The relationship between ADHD symptoms and critical incidents within a Scottish prison was investigated. A total of 198 serving prisoners were screened for both childhood and adult ADHD symptoms using the DSM-IV checklist of symptoms (DCS). Antisocial personality disorder (ASDP) was measured by the MCMI-III and used as a covariate. Behavioural problems in prison were determined using a measure of recorded critical incidents over a period of three months, including verbal and physical aggression, damage to property, self-injury, and severity of aggression. Functional impairment was determined by extreme number of critical incidents. Forty eight (24%) of the prisoners met DCS criteria for childhood ADHD, of whom 11 (23%) were fully symptomatic, 16 (33%) in partial remission and 21 (44%) in full remission. The 27 participants who were fully symptomatic or in partial remission of symptoms, had significantly more aggressive incidents and were more functionally impaired in terms of their behaviour than those participants who were symptom free, after controlling for ASPD. Symptomatic prisoners, including those in partial remission, engaged in extreme incidents in terms of both frequency and severity. It is important to identify and treat prisoners who remain symptomatic for ADHD.

Utilization of Slow-Release Ara-C Formulation for the Treatment of Meningeal Localization from Hematological Malignancies: Report of Two Cases.

Meningeal localization from hematological malignancies represents a rare event, associated with unfavourable prognosis. Treatment is based on the administration of high doses of drugs able to cross the hemato-encephalic barrier, such as Methotrexate (MTX) and cytarabine (ara-C), cranial and cranial-spinal irradiation and intrathecal (IT) administration of ara-C and/or MTX. These treatments often fail in producing a symptoms improvement and are loaded by an high rate of side effects or by a disconfortable schedule of administration. Depocyte® is a preparation of ara-C englobed in a lipidic multivescicular frame that allows a gradual and harmonic release of the drug for, at least, 14 days. This feature has allowed its utilization in treatment and prophylaxis of CNS localizations in hematological malignancies, being effective in both settings. In our Department. two patients with meningeal localizations from hematological malignancies, have been treated with Depocyte®. Patients characteristics are listed in the table. The former, a female 24 year-old patient, suffered from Burkitt's lymphoma. After second cycle of therapy in accordance with CHOP scheme, she showed signs and symptoms of meningeal localizations, characterized by cephalea, diplopia with lateral deviation of right eye and, subsequently, seizures. IT treatment with Depocyte® at the dose of 50 mg every 14 days has been started, achieving a partial remission of symptoms, with a reduction of cephalea and of frequency of seizures. The patient died because of a neurological worsening of the disease and its systemic diffusion. The latter, a male 25 year-old patient, suffering from T-ALL, has shown neurological symptoms after a cycle of induction and during CR. Symptoms have been characterized by cephalea and bilateral paralysis of the VII pair of cranial nerves, as well as by dysphagia and difficult deglutition. Treatment with Depocyte® has allowed an improvement of neurological symptoms and blasts disappeared from the CSF. In spite of therapy, remission has resulted short with a relapse of bone marrow desease. Therapy with Depocyte®, in accordance with what is already reported in literature, has proved to be an effective treatment of meningeal localizations, although a complete and lasting remission has not been achieved in our patients, related mainly to the aggressiveness of the underlying disease. However, thanks to its gradual release formulation, Depocyte® allows a lower frequency of IT administrations, compared with traditional drugs; moreover, it has shown a quite good handiness and efficacy in a short-term response of reported patients.Pazient 1Pazient 2DiagnosisBurkitt's lymphomaT-ALLAge/Sex24/F25/MDiagnosis dateMay 2005October 2005CNS ProphylaxisNoneI.T. MTXType of relapseIsolatedIsolated + CombinedTreatmentDepocyte®Depocyte®Relapse dateAugust 2005November 2005SymptomsIII pair of cranial nerves, diplopia, cephalea, seizuresVII pair of cranial nerves, cephalea, dysphagiaResponse (blasts in CNS)N.E.CREvolutionProgression, deathRelapse

Capgras Syndrome in the Modern Era: Self Misidentification on an ID Picture

Dear Editor: While living in a supervised apartment, Ms KL, aged 31 years, was hospitalized for a psychotic relapse in the course of undifferentiated schizophrenia. At admission, she presented with intense delusional (mostly persecutory) ideation, auditory hallucinations, severe anxiety, and mild depression. Her behaviour was grossly disorganized, and she required close supervision to tend to daily life activities. Her drug treatment was changed from risperidone 4 mg daily to olanzapine 30 mg daily, which elicited a partial symptom remission. Further improvement occurred with the addition of venlafaxin 225 mg daily, but she remained symptomatic and severely impaired, which led to the discussion and proposal of clozapine treatment, an option that, as of this report, she has refused. During the course of the olanzapine and venlafaxin treatment, the patient presented with a new clinical relapse, including notably increased persecutory ideation and different components of Capgras syndrome. First, she discarded her health insurance (RAMQ) plastic card because she thought that its photograph was not her own and, more specifically, because she did not recognize her nose. Of note, the patient had held this card for years without particular concern. When rechallenged with the photograph, she still contended that it had been replaced or tampered with and did not recognize her face. second, she also discarded various personal objects (such as her satchel, clothes, toilet items, and magazines) because she was convinced that they were not hers. She retrospectively admitted that she had already done so in the past; however, this behaviour was not active in the hospital before her relapse. Third, she became suspicious of her roommate, although with fluctuating conviction, because she thought that the latter had been replaced by someone charged with killing her. While the second and third symptoms are fairly classic, this case adds the plastic ID card, a highly meaningful feature of contemporary life, to the long list of objects (in a broad sense) misidentified in Capgras syndrome: it stands at the limit of object (in a narrow sense), face, and self-recognition. Moreover, the quality of most ID photographs is poor (which was admittedly particularly pronounced in the present case), and the patient was therefore presented with a degraded picture, the recognition of which is notably difficult for patients with schizophrenia. Because we had the opportunity to assess the occurrence of Capgras syndrome in an emerging state, we would also like to speculate on its clinical course in patients with schizophrenia. …

State-related changes in cerebral white matter may underlie psychosis exacerbation

Previous reports have described accelerated loss of cerebral white matter in schizophrenia. Others have reported changes of ventricle volumes in schizophrenic patients, with greatest increases following remission of psychotic symptoms. In this study changes in cerebral white matter volumes and psychotic symptoms were measured in 16 recently decompensated schizophrenic patients from neuroleptic-free baseline to 4 weeks later during treatment with antipsychotics. Serial white matter assessments were also performed in eight controls at similar intervals. Thirteen of 16 patients showed reduction of psychotic symptoms (reduction of SAPS scores by 24.4±12.6) during treatment. Three patients failed to respond (increase of SAPS scores by 15.7±13.8). Serial volumetric studies of cerebral white matter during the 4-week period showed a decrease of white matter volume in the responders by 8.2±8.2 cm 3 ( P=0.003). Patients who failed to respond showed a non-significant increase in white matter during the same period by 11.4±11.7 cm 3. Absolute and percentage changes change in white matter volumes during the 4-week period were positively correlated with changes in SAPS scores (both P<0.01). Cerebral white matter, composed of myelin-containing oligodendrocytes, is highly sensitive to excitotoxicity. Swelling of myelin and of white matter, associated interference with the speed of neurotransmission through myelinated axons, and dyssynchrony of information processing by subcortical and cortical networks may be associated with psychosis exacerbation. Partial remission of symptoms may mark temporary reduction of an active, toxic process that interferes with information processing.