Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE)

BACKGROUND: Although electroconvulsive therapy (ECT) has been shown to be extremely effective for the acute treatment of major depression, it has never been systematically assessed as a strategy for relapse prevention. OBJECTIVE: To evaluate the comparative efficacy of continuation ECT (C-ECT) and the combination of lithium carbonate plus nortriptyline hydrochloride (C-Pharm) in the prevention of depressive relapse. DESIGN: Multisite, randomized, parallel design, 6-month trial performed from 1997 to 2004. SETTING: Five academic medical centers and their outpatient psychiatry clinics. PATIENTS: Two hundred one patients with Structured Clinical Interview for DSM-IV-diagnosed unipolar depression who had remitted with a course of bilateral ECT. INTERVENTIONS: Random assignment to 2 treatment groups receiving either C-ECT (10 treatments) or C-Pharm for 6 months. MAIN OUTCOME MEASURE: Relapse of depression, compared between the C-ECT and C-Pharm groups. RESULTS: In the C-ECT group, 37.1% experienced disease relapse, 46.1% continued to have disease remission at the study end, and 16.8% dropped out of the study. In the C-Pharm group, 31.6% experienced disease relapse, 46.3% continued to have disease remission, and 22.1% dropped out of the study. Both Kaplan-Meier and Cox proportional hazards regression analyses indicated no statistically significant differences in overall survival curves and time to relapse for the groups. Mean +/- SD time to relapse for the C-ECT group was 9.1 +/- 7.0 weeks compared with 6.7 +/- 4.6 weeks for the C-Pharm group (P = .13). Both groups had relapse proportions significantly lower than a historical placebo control from a similarly designed study. CONCLUSIONS: Both C-ECT and C-Pharm were shown to be superior to a historical placebo control, but both had limited efficacy, with more than half of patients either experiencing disease relapse or dropping out of the study. Even more effective strategies for relapse prevention in mood disorders are urgently needed.     

Clopidogrel Responsiveness in Patients Undergoing Peripheral Angioplasty

Purpose

To investigate the incidence and clinical significance of platelet responsiveness in patients receiving clopidogrel after peripheral angioplasty procedures.

Materials and Methods

This prospective study included patients receiving antiplatelet therapy with clopidogrel 75 mg after infrainguinal angioplasty or stenting and who presented to our department during routine follow-up. Clopidogrel responsiveness was tested using the VerifyNow P2Y12 Assay. Patients with residual platelet reactivity units (PRU) ≥ 235 were considered as nonresponders (NR group NR), whereas patients with PRU < 235 were considered as normal (responders [group R]). Primary end points were incidence of resistance to clopidogrel and target limb reintervention (TLR)-free survival, whereas secondary end points included limb salvage rates and the identification of any independent predictors influencing clinical outcomes.

Results

In total, 113 consecutive patients (mean age 69 ± 8 years) with 139 limbs were enrolled. After clopidogrel responsiveness analysis, 61 patients (53.9 %) with 73 limbs (52.5 %) were assigned to group R and 52 patients (46.1 %) with 66 limbs (47.5 %) to group NR. Mean follow-up interval was 27.7 ± 22.9 months (range 3–95). Diabetes mellitus, critical limb ischemia, and renal disease were associated with clopidogrel resistance (Fisher’s exact test; p < 0.05). According to Kaplan–Meier analysis, TLR-free survival was significantly superior in group R compared with group NR (20.7 vs. 1.9 %, respectively, at 7-year follow-up; p = 0.001), whereas resistance to clopidogrel was identified as the only independent predictor of decreased TLR-free survival (hazard rate 0.536, 95 % confidence interval 0.31–0.90; p = 0.01). Cumulative TLR rate was significantly increased in group NR compared with group R (71.2 % [52 of 73] vs. 31.8 % [21 of 66], respectively; p < 0.001). Limb salvage was similar in both groups.

Conclusion

Clopidogrel resistance was related with significantly more repeat interventions after peripheral angioplasty procedures.     

Airway obstruction in children with cerebral palsy: Need for tracheostomy?

Objective

To examine the progress of the airway obstruction over time in children with cerebral palsy (CP) and the timing of any interventions.

Methods

The medical notes of patients with CP younger than 16 years admitted with airway obstruction to a tertiary referral Pediatric Otolaryngology Center from 2006 to 2012 were retrospectively reviewed. The gender, age of referral, co-morbidities, type of surgical intervention and age this was performed and the time interval between sequential surgeries were documented.

Results

Fifteen children with CP and airway obstruction were admitted, eight boys and seven girls with an average age of referral 8 years (range 3–13.3 years). Adenotonsillectomy was performed in 11/15 patients at a mean age of 9.1 years (range 4.5–14 years). Tracheostomy was performed in 8/15 children at an average age of 11.6 years (range 7.5–15 years). Seven out of 11 patients having undergone adenotonsillectomy, required tracheostomy after an average time interval of 1.9 years (range 0.5–3.5 years). Tracheostomy was performed in 80% of referred patients with CP older than 10 years, while surgical intervention was uncommon in children younger than 5 years. There was a statistically significant correlation between the age of the children and the performance of a tracheostomy (Pearson's correlation coefficient 0.68, p = 0.005).

Conclusions

The severity of the airway obstruction in children with CP tends to increase with age. We postulate that this increase results from worsening hypotonia of pharyngeal musculature. Children with CP and severe upper airway obstruction are likely to require tracheostomy as they grow older.     

Validation of the High-Risk Pregnancy Stress Scale in a sample of hospitalized Greek high-risk pregnant women

ABSTRACT

The aim of the authors in this study was to determine the psychometric properties of the Greek adaptation of the High-Risk Pregnancy Stress Scale (HRPSS) in a sample of high-risk hospitalized pregnant women. The sample consisted of 133 high-risk pregnant women with gestational age from 9 to 37 weeks. Data were collected between February and June of 2014. HRPSS was “forward–backward” translated from English to Greek. Principal axis factoring with promax rotation was used to test the factor structure of the HRPSS. Measures of state anxiety (STAI) and depressive symptoms (EPDS) were used to assess the convergent validity of the HRPSS. Exploratory factor analysis suggested three factors: concerns of pregnancy, movement restriction, and isolation and restriction of external activities. Construct validity was confirmed by computing correlations between the HRPSS and constructions of anxiety and depressive symptoms. Internal consistency reliability was satisfactory (α = 0.813). The original factor structure of the HRPSS was only partly replicated. The results of the exploratory factor analysis suggested that a three-factor solution instead of a two-factor solution would be the most adequate. The HRPSS is an appropriate measure for assessing the levels of concerns regarding pregnancy outcome, movement restriction, isolation, and external activity restrictions in Greek high-risk pregnant women.     

Self-esteem and aggression in women: differences between female prisoners and women without criminal records

Contradictory findings have been reported regarding the association between self-esteem and aggression. Most studies have dealt with non-criminal populations. This study aimed to explore the relationship between self-esteem and aggression and investigate possible differences in self-esteem and aggression between female inmates and women without criminal records (non-criminals) in the prefecture of Attica, Greece. One hundred fifty-seven female inmates in the Attica’s Korydallos Female Prison and 150 non-criminals from Attica’s general population completed the Buss & Perry Aggression Questionnaire and Rosenberg’s Self-esteem Scale between February 2012 and April 2014. Lower self-esteem was associated with higher aggression among women independent of criminality. Self-esteem was lower in inmates (Mean = 18.06, SD = 6.19) than in non-criminals (Mean = 21.65, SD = 4.90, p < .001). Female prisoners presented higher aggression than non-criminals (unadjusted Mean = 78.40, SD = 23.60 versus Mean = 68.82, SD = 14.95, p < .001). However, after adjusting for age, education and self-esteem, this difference was no longer statistically significant (p = .127). Further studies, especially in female offenders, should be conducted to broaden our understanding of female aggression with a view to developing and promoting focused therapeutic procedures.     

Periodontitis and atherogenesis: causal association or simple coincidence?

OBJECTIVES: The aim of this study was to assess the systemic effects of treating severe widespread periodontitis in a population of otherwise healthy individuals by examining treatment associated changes in markers of inflammation that are also implicated in cardiovascular atherosclerotic diseases. The potential impact of specific polymorphisms in cytokine genes known to influence both periodontitis and cardiovascular diseases was also examined. MATERIALS AND METHODS: A convenience sample of patients affected with severe generalised periodontitis was enrolled into a prospective single blind longitudinal intervention trial with a 6 months follow-up. Serum C-reactive protein (CRP) and interleukin-6 (IL-6) levels were assessed by high-sensitivity assays. Serological and clinical periodontal parameters were evaluated at baseline, 2 and 6 months after completion of non-surgical periodontal therapy. Results: In the 94 subjects that completed this pilot trial improvements in all clinical periodontal parameters were achieved. These were accompanied with significant reductions in serum IL-6 and CRP concentrations. In a multivariate model, serum CRP levels were significantly associated with the outcome of periodontal treatment after correcting for potential covariates (age, body mass index, gender, smoking) and polymorphisms in the IL-6 (-174 C/G) and IL-1A (-889) genes. A median decrease in serum CRP of 0.5 mg/l (95% CI 0.4-0.7 mg/l) was observed 6 months after completion of periodontal therapy in this population. Subjects with above average response to periodontal therapy (<30 residual pockets and <30% of sites bleeding on probing) accounted for the observed improvement in serum CRP. CONCLUSIONS: Control of periodontitis, achieved with non-surgical periodontal therapy, significantly decreased serum mediators and markers of acute phase response. The significance of the serum response was associated with the half of the population that responded better to non-surgical periodontal therapy. The results of this pilot study indicate that severe generalised periodontitis causes systemic inflammation. This is consistent with a causative role of periodontitis in atherogenesis.