Diagnostic and psychosocial differences in psychiatrically hospitalized military service members with single versus multiple suicide attempts

Introduction

Individuals with multiple versus single suicide attempts present a more severe clinical picture and may be at greater risk for suicide. Yet group differences within military samples have been vastly understudied.

Purpose

The objective is to determine demographic, diagnostic, and psychosocial differences, based on suicide attempt status, among military inpatients admitted for suicide-related events.

Method

A retrospective chart review design was used with a total of 423 randomly selected medical records of psychiatric admissions to a military hospital from 2001 to 2006.

Results

Chi-square analyses indicated that individuals with multiple versus single suicide attempts were significantly more likely to have documented childhood sexual abuse (p =.025); problem substance use (p = .001); mood disorder diagnosis (p = .005); substance disorder diagnosis (p =.050); personality disorder not otherwise specified diagnosis (p =.018); and Axis II traits or diagnosis (p = .038) when compared to those with a single attempt history. Logistic regression analyses showed that males with multiple suicide attempts were more likely to have problem substance use (p = .005) and a mood disorder diagnosis (p =.002), while females with a multiple attempt history were more likely to have a history of childhood sexual (p =.027).

Discussion

Clinically meaningful differences among military inpatients with single versus multiple suicide attempts exist. Targeted Department of Defense suicide prevention and intervention efforts that address the unique needs of these two specific at-risk subgroups are additionally needed.     

The association of interpersonal trauma with somatic symptom severity in a primary care population with chronic pain: Exploring the role of gender and the mental health sequelae of trauma

Objective

Female trauma survivors develop somatic symptoms more frequently than males. We propose a model for somatic symptom development among trauma survivors, focusing on gender.

Methods

Among 597 urban primary care patients with chronic pain, we examined the association between somatic symptom severity and three interpersonal trauma types: 1) sexual trauma (ST), 2) intimate partner violence (IPV), and 3) childhood trauma history (≥ 3 adverse childhood experiences (3 + ACE)). We developed a structural equation model in which PTSD, depression, and substance abuse were evaluated as potential mediators of the path between trauma exposure and somatic symptom severity, and explored the role of gender in this model.

Results

350 (59%) respondents were female; the mean age was 47. Women reported significantly more somatic symptoms than men, although somatic symptoms were increased among all interpersonal trauma survivors. In models in which the potential intervening variables are considered in aggregate, we did not find a signficant interaction between gender and trauma on somatic symptom severity, with the exception of 3 + ACEs. A structural equation model showed depression and substance abuse, for men, and depression, for women, were associated with somatic symptom severity. PTSD was not associated with somatic symptom severity. Paths from trauma exposures to mental health sequelae were stronger for men.

Conclusions

Women have more severe somatic symptoms. With the exception of 3 + ACEs, the association between trauma and somatic symptoms is amplified in both genders. Structural equation models showed the pathways differed by gender in function and strength of association.     

Impulsivity in children and adolescents with mood disorders and unaffected offspring of bipolar parents

Objective

Increased impulsivity seems to be present across all phases of bipolar disorder (BD). Impulsivity may therefore represent an endophenotype for BD, if it is also found among normal individuals at high genetic risk for mood disorders. In this study, we assessed impulsivity across four different groups of children and adolescents: patients with BD, major depressive disorder (MDD) patients, unaffected offspring of bipolar parents (UO), and healthy controls (HC).

Subjects and Methods

52 patients with BD, 31 with MDD, 20 UO, and 45 HC completed the Barratt Impulsiveness Scale (BIS-11), an instrument designed to measure trait impulsivity.

Results

UO displayed significantly higher total BIS-11 impulsivity scores than HC (p = 0.02) but lower scores than BD patients (F = 27.12, p < 0.01). Multiple comparison analysis revealed higher BIS-11 total scores among BD patients when compared to HC (p < 0.01) and UO (p < 0.01). MDD patients had higher BIS-11 scores when compared to HC (p < 0.01). Differences between MDD patients and UO, as well as between MDD and BD patients, were not statistically significant.

Conclusion

Our findings suggest that trait impulsivity is increased among children and adolescents with mood disorders, as well as in unaffected individuals at high genetic risk for BD.     

The relationship between impulsivity and lipid levels in bipolar patients: does temperament explain it?

Background

The aim of this study was to investigate whether there was a relationship between impulsivity and lipid levels in patients with bipolar disorder (BD) and to examine the correlation of impulsivity and lipid levels with temperament subtypes.

Methods

For this purpose, one hundred patients who were admitted to our out-patient unit for routine controls, had been in remission for at least 8 weeks, and diagnosed as BD according to the DSM-IV were evaluated consecutively. Impulsivity and temperament were evaluated with the BIS-11 and the TEMPS-A. Blood samples were obtained to measure levels of lipids (cholesterol, triglyceride, high density lipoprotein-HDL, low density lipoprotein-LDL).

Results

A weak correlation was found between impulsivity scores and triglyceride levels (r = 0.190, p = 0.050). Correlation was found between impulsivity scores and depressive, anxious, cyclothymic, and irritable temperaments (r = 0.371, p < 0.001; r = 0.458, p < 0.001; r = 0.541, p < 0.001; r = 0.530, p < 0.001), while triglyceride levels were only related with depressive and anxious temperaments (r = 0.485, p = 0.001 and r = 0.391, p = 0.006).

Conclusions

Temperament is an important mediator of the relationship between lipid levels and trait impulsivity in patients with BD.     

Association of elevated plasma viscosity with small vessel occlusion in ischemic cerebral disease

Introduction

Elevated plasma viscosity (PV) is observed in patients with vascular risk factors, such as diabetes mellitus or arterial hypertension. In this study we investigated the association of plasma viscosity and the different clinical and radiological entities of cerebral ischemia.

Methods

PV of 465 consecutively admitted patients with clinical symptoms of acute cerebral ischemia without radiological signs of bleeding was measured. Data is expressed as median [range] unless stated otherwise. p < 0.05 was considered statistically significant.

Results

Patients with acute cerebral ischemia (TIA or Stroke) showed increased PV (TIA 1.27mPas [1.07-1.53], stroke 1.27mPas [1.07-1.56]) compared to patients without cerebral ischemia (Mimics) (1.23mPas [1.06-1.42]). The group with radiologically proven small vessel disease (SVD) had a significantly higher mean values of PV (1.29mPas [1.06-1.54]) compared to those with signs of large vessel disease or cardioembolic events (1.22mPas [1.07-1.56], p < 0.001).Patients with chronic heart failure (p = 0.007), arterial hypertension (p < 0.001) and diabetes mellitus (p = 0.002) had higher PV compared to patients without these cardiovascular risk factors. Hyperlipidemia or nicotine abuse showed no relation to PV.

Conclusion

Elevated PV is not only associated TIA and Stroke but is also found in patients with radiological signs of cerebral SVD. High levels of PV could be an underestimated risk for TIA and Stroke and participate in the complex pathophysiology of SVD. Prospective observational and interventional studies are warranted for further evaluation of PV in neurological ischemic diseases.     

Atorvastatin favorably modulates proinflammatory cytokine profile in patients following deep vein thrombosis

Background

Venous thromboembolism (VTE) has been shown to be associated with inflammation. Statins that might reduce VTE risk have been found to exert anti-inflammatory properties in patients at cardiovascular risk. We sought to investigate whether anti-inflammatory effects of atorvastatin can be observed in VTE patients.

Materials and Methods

Atorvastatin 40 mg/d was given for 3 days to 26 consecutive VTE patients following discontinuation of anticoagulant therapy and 25 controls. We evaluated interleukin (IL)-1b, IL-6, IL-8, IL-10, soluble P-selectin and von Willebrand factor (vWF) antigen in peripheral venous blood.

Results

The VTE patients displayed higher C-reactive protein (p = 0.013), IL-1b (p = 0.03), IL-8 (p = 0.03) and vWF (p < 0.0001) compared with the controls. In VTE patients atorvastatin decreased IL-6 (p = 0.0003), IL-8 (p = 0.003) and P-selectin (p < 0.0001), but increased IL-10 (p = 0.001), with no association with C-reactive protein or cholesterol-lowering effects. Atorvastatin reduced IL-1b (p = 0.01), IL-6 (p = 0.03) and P-selectin (p = 0.002) in controls. Residual venous thrombosis was associated with elevated IL-6 and P-selectin, whereas patients with proximal deep vein thrombosis showed elevated P-selecitn prior to and following statin administration (all p < 0.05).

Conclusion

A 3-day administration of atorvastatin reduces inflammation without decrease in C-reactive protein in VTE patients.     

Mid-term results of self-testing of the international normalized ratio in adults with a mechanical heart valve

Background

Commonly the frequency of international normalized ratio (INR) monitoring with a conventional laboratory test in stable patients is once a month. When using a dedicated personal device for INR assessment, the frequency may be increased to two or more times a month.

Objective

To show that INR assessed by self-measurement at home is reliable and feasible in the mid-term and improves medical care.

Patients and methods

All patients in the study on INR self-measurement (clinical trial.gov: NCT00925197), conducted between 2004 and 2007, were re-contacted for mid-term follow-up. One hundred and seventy eight out of 192 patients who participated in the study answered a questionnaire. The average follow-up time was 4.2 years (± 1) for the self-measurement group and 4.9 years (± 1) for the laboratory-analyzed control group.

Results

Only 26 patients (group A) continued to use INR self-measurement to monitor treatment with vitamin K antagonists (VKA). The main reasons to stop INR self-measurement were its high cost and difficulty in obtaining strips. There were significantly fewer bleeding complications (p = 0.04) and complications related to VKA (p = 0.01) in self-measured patients compared to the control group. Feelings of security and quality of life were also significantly better (p = 0.002) for self-measured patients.

Conclusion

Many patients with a mechanical heart valve, who self-measured INR, continue to use this method for their follow-up because of its positive effects on their health and quality of life.     

Residual perfusion defects in patients with pulmonary embolism are related to impaired fibrinolytic capacity

Background

Few studies investigated the relationship between fibrinolysis abnormalities and residual pulmonary perfusion defects after acute pulmonary embolism (PE).

Objective

To assess the fibrinolytic profile in patients with prior PE in relation to the extent of scintigraphically detectable residual perfusion abnormalities.

Patients and methods

We studied 71 consecutive patients with a prior episode of PE, who were examined after one year of the incident embolic event, and at least one month after anticoagulation withdrawal. They underwent lung scintigraphy to assess the recovery of pulmonary perfusion, echocardiography and chest radiography to look for signs of pulmonary hypertension. Clot formation and lysis were evaluated by two turbidimetric methods: Clot and Lysis Assay and Clot Lysis Time. We also measured the in vitro plasmin-mediated lysis of fibrin from purified fibrinogen, and the circulating levels of fibrinolytic inhibitors. The sample was split in two categories based on the extent of residual perfusion defects: < 10% (n = 53), ≥ 10% (n = 18).

Results

Patients with perfusion defects > 10% had significantly longer lysis time (p < 0.05), and higher levels of plasminogen activator inhibitor-1 (p < 0.01) than those with perfusion defects < 10%. The time interval between symptoms onset and PE diagnosis (time-to-diagnosis) was significantly longer in patients with perfusion defects > 10% than in the others (p = 0.005). In multivariate logistic regression, both lysis time and time-to-diagnosis were independently associated with perfusion defects > 10% (p < 0.001). None of the sampled patients had echocardiographic or radiologic signs of pulmonary hypertension.

Conclusion

Prolonged time-to-diagnosis and fibrinolysis imbalance are independent predictors of incomplete perfusion recovery after acute PE.     

Influence of attention-deficit/hyperactivity disorder on binge eating behaviors and psychiatric comorbidity profile of obese women

Objective

Previous studies have reported higher prevalence rates of attention-deficit/hyperactivity disorder (ADHD) both in eating disorders (ED) and in obese patients. We compared the psychiatric comorbidity profile of obese ADHD women with non-ADHD obese women and how ADHD symptoms impact in binge eating behaviors.

Design

Cross-sectional study of a clinical sample.

Subjects

171 adult women were evaluated at a specialized clinic in obesity and ED.

Measurements

Participants complete a semi-structured interview and psychopathology rating scales. A hierarchical regression model was employed to predict binge eating behavior.

Results

Obese ADHD patients had a larger number of psychiatric comorbidities (p < 0.001), especially Substance Abuse Disorders, and higher scores on psychopathology rating scales (p < 0.05). The highest prediction for binge eating in the regression model was the presence of depressive symptoms, followed by ADHD inattention symptoms and trait-impulsivity.

Conclusion

ADHD should be routinely evaluated in obese since it is related with more severe psychopathology. Depressive symptoms can predict the presence of binge eating in obese patients.     

The association between childhood trauma and lipid levels in an adult low-income,minority population

Background

The objective of this study is to investigate the association between childhood trauma and lipid profiles in adults from a highly traumatized population at-risk for cardiovascular disease.

Method

We recruited 452 participants, primarily African-American and of low socioeconomic status, from general medical clinics in a large urban hospital. We performed direct comparisons, univariate analysis of variance and regression analyses together and separated by sex, examining the associations of child abuse, body mass index, lipid lowering drug use, blood pressure, age, and substance use to HDL levels and HDL/LDL ratios.

Results

A history of moderate to severe levels of childhood trauma and abuse was associated with a significant decrease in HDL levels (P≤ .01) and HDL/LDL ratios (P≤ .001) relative to males with low levels of abuse. This relationship held when the status of lipid-lowering drugs was considered. When controlling for age, substance abuse, tobacco use, and adult trauma, the effects of childhood trauma remained significant. We found a significant child abuse by sex interaction on HDL/LDL ratios [F(1,369)=13.0, P≤ .0005] consistent with a differential effect of trauma on dyslipidemia in male but not female subjects.

Conclusions

Our data suggest that childhood trauma exposure, obtained with self-report measures, may contribute to increased risk of cardiovascular disease by way of stress-mediated alterations of lipid concentration and composition in male, but not female, subjects.     

Increased thrombin generation in splanchnic vein thrombosis is related to the presence of liver cirrhosis and not to the thrombotic event

Introduction

In recent years there have been increasing evidence associating liver disease with hypercoagulability, rather than bleeding. The aim of the study was to evaluate the haemostatic potential in patients with liver disease.

Patients and methods

We measured thrombin generation in the presence and absence of thrombomodulin in patients with portal vein thrombosis (PVT, n = 47), Budd-Chiari syndrome (BCS, n = 15) and cirrhosis (n = 24) and compared the results to those obtained from healthy controls (n = 21). Fifteen patients with PVT and 10 patients with BCS were treated with warfarin and were compared to an equal number of patients with atrial fibrillation matched for prothrombin time-international normalized ratio. We assessed resistance to thrombomodulin by using ratios [marker measured in the presence/absence of thrombomodulin].

Results

There were no differences in thrombin generation between patients on warfarin treatment and their controls. Cirrhotic patients generated more thrombin in the presence of thrombomodulin and exhibited thrombomodulin resistance compared to controls [p = 0.006 for endogenous thrombin potential (ETP) and p < 0.001 for peak thrombin and both ratios ETP and peak] and patients with non-cirrhotic PVT (p = 0.001, p = 0.006, p < 0.001, p < 0.001 for ETP, peak, ratio ETP, ratio peak, respectively). The patients with cirrhotic PVT exhibited higher ETP (p = 0.044) and peak (p = 0.02) in the presence of thrombomodulin than controls, as well as thrombomodulin resistance (ETP and peak ratios: p = 0.001).

Conclusions

Hypercoagulability and thrombomodulin resistance in patients with cirrhosis were independent of the presence of splanchnic vein thrombosis. The hypercoagulability in patients with cirrhotic PVT could have implications for considering longer or more intensive treatment with anticoagulants in this group.     

Equivalent brain SPECT perfusion changes underlying therapeutic efficiency in pharmacoresistant depression using either high-frequency left or low-frequency right prefrontal rTMS

Background

Functional neuroimaging studies have suggested similar mechanisms underlying antidepressant effects of distinct therapeutics.

Objective

This study aimed to determine and compare functional brain patterns underlying the antidepressant response of 2 distinct protocols of repetitive transcranial magnetic stimulation (rTMS).

Methods

99mTc-ECD SPECT was performed before and after rTMS of dorsolateral prefrontal cortex in 61 drug-resistant right-handed patients with major depression, using high frequency (10 Hz) left-side stimulation in 33 patients, and low frequency (1 Hz) right-side stimulation in 28 patients. Efficiency of rTMS response was defined as at least 50% reduction of the baseline Beck Depression Inventory score. We compared the whole-brain voxel-based brain SPECT changes in perfusion after rTMS, between responders and non-responders in the whole sample (p < 0.005, uncorrected), and separately in the subgroup of patients with left- and right-stimulation.

Results

Before rTMS, the left- and right-prefrontal stimulation groups did not differ from clinical data and brain SPECT perfusion. rTMS efficiency (evaluated on % of responders) was statistically equivalent in the two groups of patients. In the whole-group of responder patients, a perfusion decrease was found after rTMS, in comparison to non-responders, within the left perirhinal cortex (BA35, BA36). This result was secondarily confirmed separately in the two subgroups, i.e. after either left stimulation (p = 0.017) or right stimulation (p < 0.001), without significant perfusion differences between these two subgroups.

Conclusions

These data show that distinct successful rTMS protocols induce equivalent brain functional changes associated to antidepressive efficiency, consisting to a remote brain limbic activity decrease within the left perirhinal cortex. However, these results will have to be confirmed in a double-blind randomized trial using a sham control group.     

Religious involvement is associated with greater purpose,optimism, generosity and gratitude in persons with major depression and chronic medical illness

Objective

Religious involvement may help individuals with chronic medical illness cope better with physical disability and other life changes. We examine the relationships between religiosity, depressive symptoms, and positive emotions in persons with major depression and chronic illness.

Methods

129 persons who were at least somewhat religious/spiritual were recruited into a clinical trial to evaluate the effectiveness of religious vs. secular cognitive behavioral therapy. Reported here are the relationships at baseline between religious involvement and depressive symptoms, purpose in life, optimism, generosity, and gratefulness using standard measures.

Results

Although religiosity was unrelated to depressive symptoms (F = 0.96, p = 0.43) and did not buffer the disability–depression relationship (B = − 1.56, SE 2.90, p = 0.59), strong relationships were found between religious indicators and greater purpose, optimism, generosity, and gratefulness (F = 7.08, p < 0.0001).

Conclusions

Although unrelated to depressive symptoms in the setting of major depression and chronic medical illness, higher religious involvement is associated with positive emotions, a finding which may influence the course of depression over time.     

Predictors of attempted inferior vena cava filters retrieval in a tertiary care centre

Background

Retrieval rates of optional recovery inferior vena cava (IVC) filters in US hospitals range from 11 - 70%. We conducted a retrospective study in a Canadian tertiary care centre to determine retrieval rates and predictors of filter removal.

Methods

Consecutive patients who had a retrievable IVC filter inserted or removed between January 2007 and December 2010 were identified. Data collected included baseline demographics, indications for filter insertion and removal, documentation of an IVC filter management plan, reasons for non-retrieval, complications, and death.

Results

275 patients with a median age of 60 years were followed in hospital for a median of 17 patient-days (range 1–876). Indications for filter placement were acute or prior VTE with contraindication to anticoagulation (72.4%), high risk of PE (11.3%) and primary prophylaxis (13.8%). Retrieval was attempted in 165 patients (60%) and was successful in 146 patients (53.1%). The most common reason for failed retrieval was filter thrombus. Predictors of attempted retrieval included documentation of filter plan (odds ratio [OR] 16.7; p < 0.001), surgical indication for IVC filter insertion (OR 4.8; p = 0.002), age ≤ 70 years (OR 3.8; p = 0.001), Hematology service involvement (OR 3.0; p = 0.006), and presence of metastatic cancer (OR 0.2; p = 0.001). Thrombotic complications occurred in 48 patients, including 3 patients who died of fatal PE.

Conclusion

Our filter retrieval rate is suboptimal. Improvements in follow-up documentation or a dedicated clinical service may help increase retrieval rates.     

Personality traits and childhood trauma as correlates of metabolic risk factors: the Netherlands Study of Depression and Anxiety (NESDA)

Objective

Personality and childhood trauma may affect cardiovascular disease (CVD) risk. However, evidence for an association with metabolic risk factors for CVD is limited and ambiguous. Moreover, despite their interrelatedness, personality and childhood trauma were not yet studied simultaneously. Therefore, we aimed to explore whether personality and childhood trauma are correlates of metabolic risk factors.

Methods

Among 2755 participants of the Netherlands Study of Depression and Anxiety (NESDA), we investigated through linear regression models whether Big Five personality traits (i.e., extraversion, openness, agreeableness, neuroticism and conscientiousness) and childhood trauma type (i.e., emotional neglect, and psychological, physical and sexual abuse) were correlates of metabolic risk factors (i.e., lipids, waist circumference (WC), glucose and blood pressure). Basic covariates (i.e., age, sex and income level), lifestyle, severity of depressive symptoms and years of education were taken into account.

Results

Openness was the most robust favorable correlate, and sexual abuse was the most robust unfavorable correlate of lipids and WC, and of overall metabolic risk (β = −.070; p < .001 and β = .035; p = .04, respectively).

Conclusions

People with a low openness trait and those who experienced childhood sexual abuse are at higher risk of dyslipidemia and abdominal obesity.     

Towards a unitary perspective between Post-Traumatic Stress Disorder and Substance Use Disorder. Heroin use disorder as case study

Background

Genetic, neurobiological, environmental and psychosocial mechanisms have received considerable attention in exploring the mechanisms that underlie comorbid PTSD and SUD. PTSD and SUD are not necessarily linked by a causal relationship, as the self-medication hypothesis had supposed. They might, in fact, both be caused by a third factor that predisposes these subjects to develop the two disorders (so allowing a unitary perspective).

Methods

Using a conceptualization of the PTSD spectrum, we studied the PTSD–SUD unitary perspective by testing the correlation between severity of heroin addiction, dose of opioid medication and severity of PTSD spectrum in 82 methadone-treated, heroin-dependent patients.

Results

Canonical correlation analysis (Wilks Lambda = 0.125 F = 1.41 p = 0.014), univariate and multivariate comparisons between subgroups, identified on the basis of addiction severity, showed a highly positive correlation between the PTSD spectrum and the severity of heroin addiction. In addition, negative correlations were found between PTSD spectrum severity and methadone dose (r = 0.225; p = 0.042).

Conclusions

This strength and breadth of the correlations encourage us to move towards a unified vision of the two disorders.     

Appropriate training based on Balint groups can improve the empathic abilities of medical students: A preliminary study

Objective

Although empathy is critical in a doctor–patient relationship, empathic abilities seem to decline throughout medical school. This study aimed at examining changes in empathic abilities of fourth-year medical students who participated in an optional certificate based on Balint groups.

Methods

Thirty-four students were included in the “Balint group” certificate and compared with 129 participating in other certificates. Before the training sessions and 4 months later, they filled up the interpersonal reactivity index (IRI) and were asked to rate their emotional reactions in response to two case-reports: the first described a woman with diabetes, borderline- personality traits and a history of childhood trauma; the second, a woman with histrionic traits suffering from multiple sclerosis and hospitalized for functional symptoms. A principal component analysis extracted four factors from the 8 questions asked: empathic-approach (e.g. finding the patient touching), rejecting-attitude, intellectual-interest and fear of emotion contagion.

Results

At baseline, there were no socio-demographic or psychological differences between groups. At follow-up, an increase of IRI fantasy-scale (p = 0.02) and a decrease of IRI empathic-concern (p = 0.006) were observed, regardless of the group. Empathic-approach only increased in the “Balint group” and for the first case-report (p = 0.023), with a difference between the groups at follow-up (p = 0.003).

Conclusion

Results suggest that Balint groups may enable medical students to better handle difficult clinical situations such as those presented by borderline personalities. Our findings encourage assessing training initiatives designed at helping young medical students to take into account the emotional component of a doctor–patient relationship.     

Which psychological factors exacerbate irritable bowel syndrome? Development of a comprehensive model

Objective

There is evidence that psychological factors affect the onset, severity and duration of irritable bowel syndrome (IBS). However, it is not clear which psychological factors are the most important and how they interact. The aims of the current study are to identify the most important psychological factors predicting IBS symptom severity and to investigate how these psychological variables are related to each other.

Methods

Study participants were 286 IBS patients who completed a battery of psychological questionnaires including neuroticism, abuse history, life events, anxiety, somatization and catastrophizing. IBS severity measured by the IBS Severity Scale was the dependent variable. Path analysis was performed to determine the associations among the psychological variables, and IBS severity.

Results

Although the hypothesized model showed adequate fit, post hoc model modifications were performed to increase prediction. The final model was significant (Chi² = 2.2; p = 0.82; RMSEA < .05) predicting 36% of variance in IBS severity. Catastrophizing (standardized coefficient (β) = 0.33; p < .001) and somatization (β = 0.20; p < .001) were the only two psychological variables directly associated with IBS severity. Anxiety had an indirect effect on IBS symptoms through catastrophizing (β = 0.80; p < .001); as well as somatization (β = 0.37; p < .001). Anxiety, in turn, was predicted by neuroticism (β = 0.66; p < .001) and stressful life events (β = 0.31; p < .001).

Conclusion

While cause-and-effect cannot be determined from these cross-sectional data, the outcomes suggest that the most fruitful approach to curb negative effects of psychological factors on IBS is to reduce catastrophizing and somatization.     

Pulmonary embolism in elderly patients: Prognostic impact of the Cumulative Illness Rating Scale (CIRS) on short-term mortality

Background

Pulmonary embolism (PE) is associated with high short-term mortality in elderly patients, even when hemodynamically stable.

Methods

One hundred and seventy hemodynamically stable patients with confirmed PE (41 < 65 years and 129 ≥ 65 years) were prospectively followed for one month in order to assess whether comorbidities can predict short-term mortality in elderly patients. Upon admission, patients’ clinical characteristics (including instrumental and laboratory parameters) were evaluated, and two clinical scores were calculated: the Cumulative Illness Rating Scale (CIRS), commonly used to evaluate comorbidities in elderly patients, and the Pulmonary Embolism Severity Index (PESI).

Results

Fifteen patients (all elderly) died within one month from their PE diagnosis (mortality rate = 8.8%; 95%CI:4.6-13.1%). In these non survivors, arterial partial oxygen pressure (p < 0.0001) and saturation (p < 0.0001), pH (p = 0.001) and systolic blood pressure (p = 0.017) at admission were significantly lower than in survivors, whereas their respiratory rate (p < 0.0001), white blood cells (p < 0.0001), lactate dehydrogenase (p < 0.0001), troponin T (p = 0.001) and D-dimer (p = 0.023) were significantly higher. CIRS correlated with PESI (rho = 0.54, p < 0.0001), and was higher in non-survivors (p = 0.002). The age- and sex-adjusted odds ratio of 1-month mortality was 1.91 (95%CI:1.24-2.95) for every 1-point increase in CIRS. The AUC was 0.78 (95%CI:0.67-0.89) for the logistic model containing CIRS, and 0.88 (95%CI:0.79-0.96) for that containing PESI (p = 0.059).

Conclusions

In elderly patients with PE, CIRS demonstrated a fairly good performance in predicting short-term mortality. Its easiness and suitability for use in common clinical practice make CIRS a potentially useful prognostic score for short-term mortality in these patients.     

Economic evaluation of rFVIIa high initial dose compared to rFVIIa standard initial dose in patients with haemophilia with inhibitors using the Czech HemoRec registry

Introduction

In the treatment of bleeds in haemophilia patients with inhibitors, a high initial dose of recombinant Factor VIIa (rFVIIa) provides at least equal efficacy and a similar safety profile to a standard initial dose. However, no pharmacoeconomic comparison between these dosing regimens has previously been performed. Here, we assess the pharmacoeconomics of high (> 120 μg/kg) versus standard (≤ 120 μg/kg) initial rFVIIa dose in inhibitor patients and the impact of time to treatment initiation on costs and outcomes.

Methods

In a retrospective analysis, observational data on bleed characteristics, rFVIIa treatment, hospitalizations and outcomes were extracted from the Czech Republic HemoRec registry. Crude comparisons and generalized linear regression modelling (GLM; correcting for patient differences) were performed to compare costs and outcomes between the high and standard initial dosing groups.

Results

Of 314 rFVIIa-treated bleeding episodes (12 inhibitor patients), most were spontaneous joint bleeds and 67.5% were treated with a high initial dose. In the crude comparison, high initial rFVIIa dosing was associated with a lower mean number of doses needed to achieve haemostasis compared with standard dosing (p < 0.001), but higher total dose and costs (p ≤ 0.008). However, regression analyses revealed that high initial dose was associated with similar costs (p = 0.891) and a shorter time to bleeding resolution (p = 0.014). Increasing time to treatment initiation increased both time to bleeding resolution and total costs.

Conclusion

Compared with a standard dose, a high initial rFVIIa dose may improve treatment outcomes without increasing costs. Early treatment initiation may reduce treatment costs.