Two-year prospective study of major depressive disorder in HIV-infected men.

OBJECTIVE: The risks and factors contributing to major depressive episodes in HIV infection remain unclear. This 2-year prospective study compared cumulative rates and predictors of a major depressive episode in HIV-infected (HIV+) men (N=297) and uninfected (HIV-) risk-group controls (N=90). METHODS: By design participants at entry were without current major depression, substance dependence or major anxiety disorder. Standardized neuromedical, neuropsychological, neuroimaging, life events, and psychiatric assessments (Structured Clinical Interview for DSM III-R) were conducted semi-annually for those with AIDS, and annually for all others. RESULTS: Lifetime prevalence of major depression or other psychiatric disorder did not differ at baseline between HIV+ men and controls. On a two-year follow-up those with symptomatic HIV disease were significantly more likely to experience a major depressive episode than were asymptomatic HIV+ individuals and HIV-controls (p<0.05). Episodes were as likely to be first onset as recurrent depression. After baseline disease stage and medical variables associated with HIV infection were controlled, a lifetime history of major depression, or of lifetime psychiatric comorbidity (two or more psychiatric disorders), predicted subsequent major depressive episode (p<0.05). Neither HIV disease progression during follow-up, nor the baseline presence of neurocognitive impairment, clinical brain imaging abnormality, or marked life adversity predicted a later major depressive episode. LIMITATIONS: Research cohort of men examined before era of widespread use of advanced anti-HIV therapies. CONCLUSIONS: Symptomatic HIV disease, but not HIV infection itself, increases intermediate-term risk of major depression. Prior psychiatric history most strongly predicted future vulnerability.

Intracranial haemorrhage in patients on antithrombotics: clinical presentation and determinants of outcome in a prospective multicentric study in Italian emergency departments.

BACKGROUND: Intracranial haemorrhage (ICH) is the type of stroke associated with the highest death rate, and about 30% of ICH occurs in patients on antithrombotic treatment. This study relates clinical presentations and outcome of ICH patients on oral anticoagulant (OA) or antiplatelet (AP) therapy admitted to 33 Italian emergency departments (ED). METHODS: Consecutive patients were enrolled after cranial computed tomography (CT). Primary outcome was the Modified Rankin Scale (MRS) score at 3 months of follow-up. Common descriptive statistics were computed after stratification for traumatic or spontaneous ICH and identification of the anatomical location of bleeding. Multivariate logistic regression was used to assess predictors of death. RESULTS: We recruited 434 patients on AP therapy and 232 on OA. There were 432 spontaneous and 234 traumatic ICH patients. The proportions of AP and OA patients undergoing neurosurgery were 21.8 and 19.4%, respectively, while < 30% underwent procoagulant medical treatment. At the 3-month follow-up, the case fatality rate was 42.0%, while disability or death (MRS 3-6) was 68.1%. The odds ratio for death in OA versus AP patients was 2.63 (95% CI 1.73-4.00) in the whole population and 2.80 (95% CI 1.77-4.41) in intraparenchymal event patients. Glasgow Coma Scale, age, spontaneous event and anticoagulant use were found to be predictors of death both in traumatic and spontaneous events. CONCLUSION: This study confirms the high prevalence of death or disability in OA and AP patients with ICH. As far as the determinants of mortality and disability are concerned, the results of this study might be useful in the clinical management and allocation of resources in the ED setting. The observed low use of procoagulant therapy highlights the need for ED educational programmes to heighten the awareness of available and effective haemostatic treatments.

Densitometric study of developing femur.

The purpose of this work was to extend to long bones the study on the ossification of human fetal skeleton in relation to conceptual age by a quantitative methodological approach. Postero-anterior scans were performed on 29 dried fetal femora (from 11.5 weeks of conceptual age to term) by a Hologic QDR 1000 X-ray densitometer with Ultra-Hi-Resolution software. The results were expressed as bone mineral content (BMC, g) and bone mineral density (BMD, g/cm2). BMD was calculated on a rectangular area corresponding to the total length and minimum width of the shaft. This area was divided into five equal sections along its longitudinal axis in order to estimate the rate of ossification from a spatio-temporal point of view. Our data show that BMC has a high correlation with conceptual age during the whole prenatal life, increasing in the third trimester (r >/= 0. 96). During development, BMD is progressively less correlated with conceptual age (r = 0.95 in the first half of development, r = 0.68 in the second half), particularly according to a bidirectional gradient from the middle to the proximal and distal ends of the shaft. Our findings confirm the data obtained in our previous studies on the ossification of fetal human spines, and suggest an individual variability in bone density at term of development and particularly at the level of spongiosa, viz. in the areas mostly involved in architectural changes during the morphogenesis of the long bones.

Iatrogenic Psychoses.

Iatrogenic psychoses can cause disability, worsen previous disability, and render clinical management extraordinarily difficult. In certain cases, psychosis precedes more severe and overt toxicity, which can lead to encephalopathy or coma. This article offers an overview of iatrogenic (ie, treatment-induced) psychoses. "Pure" psychoses (ie, without confusion or mood disturbance) are emphasized. Shortcomings of available data are highlighted. The epidemiology, definition, diagnosis, differential diagnoses, risk factors, and course are discussed. Therapeutic measures include discontinuation or decreasing the dose of the suspected medication and the administration of neuroleptics, antimanics, and antidepressants. Other general principles of clinical management are given. A brief review of etiopathogenic mechanisms is offered and areas for future research are emphasized.

Sleep disturbance and HIV disease.

AIDS: HIV-associated sleep disturbance may be easy to overlook, underdiagnose, and undertreat, due to the many medical and psychosocial problems faced by people with HIV disease. Identifying the cause of the disturbance and distinguishing between sleep disturbance and fatigue are critical for effective treatment. A thorough patient history can help clinicians provide accurate diagnosis and therapy. To date, there is no known remedy to correct HIV-associated sleep disturbance. Clinicians should consider behavior modification techniques, such as relaxation training, habit training, and reversal of negative conditioning, before administering sleep medications.^ieng

Densitometric study of developing vertebral bodies.

To define the quantitative aspects of ossification of human fetal spine, we performed a high resolution densitometric study by lateral and postero-anterior scanning of five fetal spines (18-36 weeks of conceptual age) and one spine of a 4-month-old infant. The data were plotted against developmental age for each spine and vertebra. Bone mineral content increased with developmental age, with a peak at the upper lumbar level, in agreement with the ossification pattern of the spine, reported in embryological literature. Bone mineral density (BMD) was unrelated to developmental age, and showed similar trends for each vertebra in all the vertebral columns examined. The changes of BMD seems to be a phenomenon related to individual variability. This study also demonstrates that densitometric techniques may provide useful and interesting information in studies on skeletal development.

Psychiatric morbidity associated with acquired immune deficiency syndrome-related grief resolution.

This study examined acquired immune deficiency syndrome (AIDS)-related grief resolution and psychiatric morbidity in 286 human immunodeficiency virus (HIV)-positive and HIV-negative gay men examined between 1989 and 1993 in San Diego, CA. Psychiatric morbidity, mood ratings, and bereavement assessments were obtained using the Structured Clinical Interview for DSM-III-R, Hamilton Rating Scales for Depression and Anxiety, and Texas Revised Inventory of Grief. Sixty percent of the men (N = 171) reported a loss within the previous 12 months. Eighteen percent of the bereaved met criteria for unresolved grief. No differences were evident in lifetime psychiatric disorders, yet men with unresolved grief demonstrated an elevated prevalence of current major depression and panic disorder when compared with resolved grievers. Clinician sensitivity to the grief process and its relationship to psychiatric complications is an important component of comprehensive psychiatric and medical care of men at high risk for HIV during this era of AIDS.

[Synthetic salmon calcitonin suppositories for the short-term treatment of involutive osteoporosis]. / La calcitonina sintetica di salmone in supposte nel trattamento a breve termine dell'osteoporosi involutiva.

Intramuscular and intranasal synthetic salmon calcitonin (sCT) has long been used in the treatment of involutional osteoporosis. A new suppository formulation was developed and many studies demonstrated that rectally administered sCT is efficacious and well tolerated. Thirty postmenopausal women, who had a bone mineral density at the lumbar spine below the mean of age-matched women, were enrolled in this study. Using an open balanced, randomized design, the patients were allocated to two groups of treatment: sCT suppositories at the dose of 100 UI/day or 200 UI every other day for six months. Treatment with sCT suppositories caused a statistically significant decrease of pain in both study groups. Bone mineral density at lumbar spine showed an increase in both study groups with significant difference respect the basal value for the patients treated with sCT on alternate day. Based on the results of this study, we can thus conclude that sCT in suppository formulation is effective in reducing pain sintomatology, bone loss and turnover in involutional osteoporosis.

Metabolic markers for the early diagnosis of postmenopausal osteoporosis.

We performed a cross-sectional study in 147 women, 41 in premenopausal age and 106 in menopause for 1-5 years: bone mineral density (BMD) at the distal radius and annual bone loss (as shown by plasma alkaline phosphatase and osteocalcin levels, and by calcium/creatinine and hydroxyproline/creatinine in the second urine of the morning) were evaluated. A significant reduction of BMD with a significant increase of bone loss was observed with increasing duration of menopause. Furthermore, when the women were subdivided into two groups according to annual bone loss (over or under 1.7%), significant differences were found between bone mineral density in the second and third years of menopause. As this is a cross-sectional and not a longitudinal study, it confirms that, in the presence of a higher bone loss, the BMD levels are lower and consequently the theoretical definition of this parameter can allow useful information on the presumable behavior of BMD.

X-ray densitometry applied to the study of prenatal ossification.

To evaluate bone mass (BMC) and bone density (BMD) it is possible to utilize x-ray absorptiometry. This method is usually employed in clinical practice for the evaluation of metabolic osteopathies. The authors describe an application of this diagnostic technique to the study of the ossification pattern of the human vertebral column in pre- and post-natal life. On this regard, an ultra high resolution software allowed to analyze quantitative aspects of the ossification of small size vertebral bodies by lateral scans directly performed on bone specimens.

[Periodicities in the longitudinal evaluation of affective status]. / Periodicidades en la evaluación longitudinal del estado afectivo.

Both circadian and infradian rythms in Affective State (AS) are reported in 12 subjects (10 with Affective Disorders, 2 without Mental Disorder). The segmented visual scale ESTA-III was used, which yields scores for two dimensions: Mood and Drive. Self-assessment of AS was carried out every 8 hours for about a month. The statistical procedure is underlined. Theoretical implications of findings are discussed.

[Gamma-ray bone densitometry and evaluation of the patient at risk for osteoporosis]. / Densitometria ossea a raggi gamma e valutazione dei pazienti a rischio di osteoporosi.

After having briefly illustrated the main theories of photonic ray bone densitometry, the authors describe the various techniques used to evaluate bone mass and bone mineral density as accurately and precisely as possible both at an appendicular level and at lumbar and femoral sites. Since these data only provide a static measurement and are unable to provide information regarding bone mass evolution in time, a method is illustrated which is theoretically capable of identifying high risk subjects, namely those who, on the basis of simple blood and urine tests for some biochemical parameters, are likely to undergo a significant reduction in bone mass in the future. Lastly, the paper reports the preliminary results of a study carried out in immediately post-menopausal women in whom rapid loss of bone mass was followed by a greater reduction in bone mineral density measured at an appendicular level.

Effect of testosterone on bone in hypogonadal males.

Bone mineral content (BMC) and testosterone levels were evaluated and compared in 10 hypogonadal males and 10 normal, age-matched controls. In 6 of the subjects an investigation was also carried out into the effects of testosterone administration on lumbar BMC, calcitonin (CT) response to hypercalcaemia, osteocalcin (BGP) and the fasting urinary calcium/creatinine and hydroxyproline/creatinine ratios. Our results confirm that male hypogonadism is characterized by a low BMC and that testosterone administration is able to improve this parameter and to increase both basal BGP and CT response to hypercalcaemia. Testosterone therefore probably acts on bone tissue through both a direct action on osteoblast cells and an improvement in CT secretion.

Influence of estrogens on calcitonin secretion.

In this study we investigated the calcitonin (CT) pattern both in basal conditions and after calcium infusion before and one month after oophorectomy in 17 premenopausal women. In addition, 13 oophorectomized women were randomly allocated to two groups, one given hormone replacement treatment and the other untreated, and CT response to hypercalcemia was reevaluated one year later. CT response to calcium infusion was significant only before oophorectomy and one year after estrogen-progestogen treatment, whereas there was no response one month after oophorectomy or after one year without hormone replacement therapy. Our data indicate that both estrogen secretion and replacement treatment may be important factors in CT response.

ARIMA modelling of chronospsychometric self-evaluation of drive and mood.

The expanding study of biological rhythms requires the use of refined methods of time series analysis. We propose the use of ARIMA (Autoregressive Integrated Moving Averages) model, a powerful statistical tool of relatively recent development. A group of 5 patients with Affective Disorders (2 bipolars, 3 unipolars) and 1 patient with Adjustment Disorder self-assessed their AS every 8 hours for about a month. The affective state (AS) was estimated for 4 indicators: the two main constructs (Mood and Drive) of the segmented Visual Scale ESTA III and two bipolar items (Anxiety and Drowsiness). Mood and Drive are continuous variables, while Anxiety and Drowsiness are ordinal ones. Strictly speaking, ARIMA modelling is not valid with ordinal data. However, comparison of models of the two kinds of variables reveals no significant differences. This points out to a certain robustness of the method. Most of the series were non-stationary but could be transformed taking no more than two differences. The models made a very good fit of the data. Statistically significant coefficients on different lags may indicate the presence of circadian and infradian periodicities in the series. Further applications of ARIMA models to biological and psychological rhythmometry may be quite useful.

[Drive and Mode Scale for the quantification of affective states]. / La escala de ánimo-impulso para la cuantificación del estado afectivo (EA).

The Drive and Mood Scale, used in chronopsychometric studies for evaluating dimensions of Affective State, is presented. This instrument is based upon the ESTA Scale developed by Supprian and complemented on the basis of the experience gathered during research projects conducted with the Spanish version.

Epidural spinal electrostimulatory system (ESES) in the management of diabetic foot and peripheral arteriopathies.

Epidural spinal electrostimulatory system (ESES) or dorsal column stimulation (DCS) may be used for the treatment of peripheral vascular diseases of the lower extremities. ESES has been used in our metabolic and surgical department as a way to ameliorate inadequate blood supply in patients suffering from diabetic foot (seven patients), painful chronic arterial narrowing, or inoperable occlusions (25 patients). The continuous stimulation by an implantable apparatus (Medtronic model Itrel, Medtronic, Inc., Minneapolis, MN, USA) led to a reduction or disappearance of pain, an improvement in plethysmographic curves, functional performance, and trophic lesions in about 75% of the patients. The system is safe and well-tolerated by patients.

Epidural spinal electric stimulation in the treatment of ischemic pain.

Among the analgetic methodologies, epidural spinal stimulation is playing an important role in the treatment of obliterating arteriopathies. Physiopathogenetic hypotheses as well as the main indications, contra-indications and the technique performed are examined. Twenty-four patients (18 males and 6 females) underwent spinal electric stimulation and were all monitored through angiography and preliminary examinations (Doppler velocimetry, plethysmography, Laser Flo, cycloergometer test) which were repeated during the period of temporary and after the permanent stimulator was implanted. The results obtained show that electric stimulation is a reliable technique when the medical or surgical treatments are successful.