PHYSICO-DSM-VR Physical health promotion in patients with functional psychoses of the 4 Community Psychiatric Services of ULSS 20, Verona: a multicentre Randomised Controlled Study

Introduzione. La letteratura sulla comorbilit\ue0 fisica nei pazienti psicotici mostra che i pazienti con disturbi mentali gravi (come la schizofrenia e il disturbo bipolare) hanno una salute fisica peggiore e una minore aspettativa di vita rispetto alla popolazione generale. Tali risultati sono stati spiegati con un modello multi-causale. Tra i fattori di rischio sono inclusi sia fattori non modificabili (sesso, et\ue0, anamnesi famigliare) che fattori modificabili attraverso cambiamenti comportamentali e miglioramento delle cure (fumo, obesit\ue0, diabete, ipertensione e dislipidemia). Negli ultimi anni, in particolare, sono stati sviluppati programmi di intervento specifici o adattati per modificare stili di vita non salutari attraverso cambiamenti nella dieta e/o nell'attivit\ue0 fisica. Quando si trattano pazienti psicotici con farmaci antipsicotici, si dovrebbero prendere in considerazione interventi sullo stile di vita preventivi e/o individualizzati, che includano la dieta e l'attivit\ue0 fisica. Obiettivi. L'obiettivo generale dello studio \ue8 di implementare strategie di promozione della salute riguardo le abitudini alimentari e l'attivit\ue0 fisica e di studiare la loro efficacia tramite un trial controllato randomizzato in pazienti con psicosi in carico ai 4 servizi psichiatrici dell'ULSS 20 (Verona). L'ipotesi principale \ue8 che il pacchetto d'intervento porti al miglioramento nei comportamenti relativi alla dieta e all'attivit\ue0 fisica nei pazienti con psicosi, rispetto ai pazienti che riceveranno il trattamento standard. Metodi. Il programma di intervento (6 mesi) consiste in sessioni educative per i pazienti su attivit\ue0 fisica e alimentazione; camminate di gruppo sotto la guida di un allenatore esperto; sessioni educative per gli operatori dei Centri di Salute Mentale coinvolti; colloquio motivazionale per promuovere l'aderenza. I soggetti sono stati testati al baseline, a intervalli mensili e alla fine dell'intervento rispetto a stato di salute fisica, abitudini alimentari e attivit\ue0 fisica, numero di passi durante le camminate, qualit\ue0 della vita legata alla salute e soddisfazione rispetto al servizio psichiatrico. La misura di esito primaria \ue8 basata sulle raccomandazioni dell'Organizzazione Mondiale della Sanit\ue0 sulla dieta e l'esercizio fisico (almeno 5 porzioni di frutta e/o verdura al giorno; attivit\ue0 fisica moderata per almeno 30 minuti al giorno per 5 giorni a settimana). Il miglioramento di almeno un criterio OMS alla valutazione finale rispetto al baseline viene considerato un successo. Risultati. Nel gruppo sperimentale, il 40.57% (71/175) dei soggetti soddisfa un criterio in pi\uf9 al follow-up rispetto al baseline, mentre il 32.35% (55/170) nel gruppo di controllo lo fa. La differenza tra i due guppi non \ue8 statisticamente significativa (\u3c72(1) = 2.51, p = 0.11). Analizzando separatamente dieta e attivit\ue0 fisica tenendo in considerazione la partecipazione all'intervento (>60% delle sessioni), i soggetti "partecipanti" mostrano un incremento statisticamente significativo del numero di porzioni di frutta/verdura al giorno (+ 0.3) e del numero di minuti di attivit\ue0 fisica moderata a settimana (+ 80). Conclusioni. I risultati di questo trial e della fase osservazionale dello studio corrispondono con la situazione allarmante riportata dalla letteratura sull'aumentata presenza di fattori di rischio, comorbilit\ue0 fisica e mortalit\ue0 dei pazienti psichiatrici. I risultati su aspetti specifici dell'intervento mostrano una significativa differenza nelle abitudini alimentari e motorie dei soggetti che hanno partecipato ad un numero sufficiente di sessioni. La difficolt\ue0 principale sembra essere portare effettivamente questo tipo di pazienti a partecipare ad un intervento di promozione della salute. Una volta coinvolti, essi possono trarne beneficio, anche se per far raggiungere un cambiamento significativo un intervento di questo tipo necessita di ulteriori miglioramenti e metodi perfezionati.Background Literature on physical comorbidity in psychosis shows that, in comparison to the general population, patients with severe mental illness (such as schizophrenia and bipolar disorder) have worse physical health and a far shorter life expectancy. These findings have been explained with a multi-causal model including a higher prevalence of risk factors like high blood pressure, high plasma cholesterol and obesity, smoking, diabetes, tendency to self neglect, unhealthy lifestyles, medication side-effects and low socio-economical status, hence including risk factors that are inherently non-modifiable (gender, age, family history) and risk factors that are modifiable through behavioural changes and improved care (smoking, obesity, diabetes, hypertension and dyslipidaemia). In the last years, in particular, specific or adapted intervention programmes to change unhealthy lifestyles through diet and/or physical activity modifications are being developed. Preventive and individual lifestyle interventions that include diet and physical activity should be taken into account when treating schizophrenic patients with antipsychotics. Objectives The general objective of the trial is to implement health promotion strategies on dietary habits and physical exercise and to study their efficacy with a randomised controlled trial in patients with functional psychoses referred to the 4 Community Psychiatric Services (CPSs) of ULSS 20 (Verona). The main hypothesis is that the intervention package will result in the improvement of physical activity and diet-related behaviours in people with functional psychoses, compared to those receiving treatment as usual. Secondary hypotheses are the improvement of examined physical health parameters, health-related quality of life and patients satisfaction with the psychiatric services. Methods The intervention package (6 months) consists in: health education sessions for patients on physical activity and nutrition; group walking under the guide of an expert trainer; educational sessions for the mental health workers involved; motivational interviewing to promote adherence. Subjects have been tested at baseline and after the end of treatment on: physical health status, physical activity and diet habits, number of steps during walking groups, health-related quality of life, patients satisfaction with CPS. The primary outcome is based on WHO recommendations on diet and exercise (at least five servings of fruit and/or vegetables a day; moderate physical activity for at least 30 minutes on at least 5 days a week). The improvement of at least one WHO criterion at the final assessment compared to the initial one will be considered a successful change. Results In the experimental group, 40.57% (71/175) of subjects fulfil one criterion more at follow-up than at baseline, while 32.35% (55/170) of subjects of the control group do. The difference between groups is not significant (\u3c72(1) = 2.51, p = 0.11). When diet and physical activity are analysed separately according to subjects participation to the intervention (>60% of sessions attended), participants show a significant increase in the number of fruit/vegetables portions per day (+ 0.3) and in the number of minutes of moderate physical activity (+ 80) per week. Conclusions Results of this trial and the observational phase of the study correspond with the alarming situation reported by literature on the increased risk factors, physical morbidity and mortality of psychiatric patients. Results on specific aspects of the intervention revealed a significant difference in diet and physical activity habits in subjects who participated to a sufficient number of sessions. The principal issue is actually engaging this kind of population in a lifestyle intervention. Once engaged they can benefit from it, although to reach a significant change an intervention of this kind needs further improvement and refined methods

Middle ear metastasis from dormant breast cancer as the initial sign of disseminated disease 20 years after quadrantectomy.

We describe an unusual case of breast cancer metastatic to the middle ear in a 71-year-old woman. The metastasis was the initial sign of disseminated disease 20 years after the patient had undergone a quadrantectomy for her primary disease. Computed tomography (CT) demonstrated the presence of an intratympanic mass with a soft-tissue density that was suggestive of chronic inflammation. The patient underwent a canal-wall-down tympanoplasty. When a brownish mass was found around the ossicles, a mastoidectomy with posterior tympanotomy was carried out. However, exposure of the tumor was insufficient, and therefore the posterior wall of the ear canal had to be removed en bloc. Some tumor was left on the round window membrane so that we would not leave the patient with a total hearing loss. Our case highlights the limitations of CT and magnetic resonance imaging in differentiating inflammatory and neoplastic lesions

An examination of autism spectrum traits in adolescents with anorexia nervosa and their parents

There may be a link between anorexia nervosa and autism spectrum disorders. The aims of this study were to examine whether adolescents with anorexia nervosa have autism spectrum and/or obsessive-compulsive traits, how many would meet diagnostic criteria for autism spectrum disorder, and whether these traits are shared by parents

Clinical Features of Ocular Toxoplasmosis in Korean Patients

We report here the records of 10 consecutive Korean patients (10 eyes) with ocular toxoplasmosis which showed the typical clinical manifestations with seropositivity for Toxoplasma gondii specific IgG antibodies by micro-ELISA between 2006 and 2010. Nine patients were males and 1 was female; their age was 50.5±13.8 years. The most common accompanying signs were vitritis (100%), anterior uveitis (70%), and scattered white deposit (80%). Pre-existing retinochoroidal scar was found in 1 (10%) patient. All patients received antiparasitic chemotherapy and systemic corticosteroid treatment, which resolved the presenting attack and recovered the visual acuity better than initial one in 9 patients and worse in 1. Optic atrophy, cataract, and retinal neovascularization were observed during the follow-up period and recurrence was detected in 3 eyes (30%) 6 to 20 months after the initial attack. In Korea, although rarely detected and reported, ocular toxoplasmosis needs more attention in clinical field of retinal diseases

Hypercalcemia after transplant nephrectomy in a hemodialysis patient: a case report

<p>Abstract</p> <p>Introduction</p> <p>Hypercalcemia is a complication often seen in chronic hemodialysis patients. A rare cause of this condition is sarcoidosis. Its highly variable clinical presentation is challenging. Especially in patients suffering chronic kidney graft failure the nonspecific constitutional symptoms of sarcoidosis like fever, weight loss, arthralgia and fatigue may be easily misleading.</p> <p>Case presentation</p> <p>A 51 year old male developed hypercalcemia, arthralgia and B-symptoms after explantation of his kidney graft because of suspected acute rejection. The removed kidney showed vasculopathy and tubulointerstitial nephritis, which had not been overt in the biopsy taken half a year earlier. Despite explantation and withdrawal of the immunosuppression the patient's general condition deteriorated progressively. A rapid rise in serum calcium finally provoked us to check for sarcoidosis. CT scans of the lungs, broncho-alveolar-lavage and further lab tests confirmed the diagnosis.</p> <p>Conclusion</p> <p>This case demonstrates that withdrawal of immunosuppressive drugs sometimes unmasks sarcoidosis. It should be considered as differential diagnosis even in hemodialysis patients, in whom other reasons for hypercalcemia are much more common.</p

Prevalence and clinical outcomes of isolated or combined moderate to severe mitral and tricuspid regurgitation in patients with cardiac amyloidosis

Aims: Evidence on the epidemiology and prognostic significance of mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with cardiac amyloidosis (CA) is scarce. Methods and results: Overall, 538 patients with either transthyretin (ATTR, n = 359) or immunoglobulin light-chain (AL, n = 179) CA were included at three Italian referral centres. Patients were stratified according to isolated or combined moderate/severe MR and TR. Overall, 240 patients (44.6%) had no significant MR/TR, 112 (20.8%) isolated MR, 66 (12.3%) isolated TR, and 120 (22.3%) combined MR/TR. The most common aetiologies were atrial functional MR, followed by primary infiltrative MR, and secondary TR due to right ventricular (RV) overload followed by atrial functional TR. Patients with isolated or combined MR/TR had a more frequent history of heart failure (HF) hospitalization and atrial fibrillation, worse symptoms, and higher levels of NT-proBNP as compared to those without MR/TR. They also presented more severe atrial enlargement, atrial peak longitudinal strain impairment, left ventricular (LV) and RV systolic dysfunction, and higher pulmonary artery systolic pressures. TR carried the most advanced features. After adjustment for age, sex, CA subtypes, laboratory, and echocardiographic markers of CA severity, isolated TR and combined MR/TR were independently associated with an increased risk of all-cause death or worsening HF events, compared to no significant MR/TR [adjusted HR 2.75 (1.78-4.24) and 2.31 (1.44-3.70), respectively]. Conclusion: In a large cohort of patients with CA, MR, and TR were common. Isolated TR and combined MR/TR were associated with worse prognosis regardless of CA aetiology, LV, and RV function, with TR carrying the highest risk

Chinese Health Improvement Profile for people with severe mental illness: A cluster-randomized, controlled trial

© 2017 Australian College of Mental Health Nurses Inc. The aim of the present study was to establish the feasibility of conducting a full-scale trial and to estimate the preliminary effect of a Chinese Health Improvement Profile (CHIP) intervention on self-reported physical well-being of people with severe mental illness (SMI). The study used a parallel-group, open-label, cluster-randomized, controlled trial (RCT) design. Twelve community psychiatric nurses (CPN) and their corresponding 137 patients with SMI were randomized into the CHIP or treatment-as-usual (TAU) groups. After training, the CPN completed the CHIP at baseline and 12 months, and the findings were used to devise an individualized care plan to promote health behaviour change. Patients were assessed at baseline and 6 and 12 months after starting the intervention. There was an observed positive trend of improvement on the physical component subscale of SF12v2 in the CHIP group compared to the TAU group after 12 months, but the difference did not reach statistical significance (P = 0.138). The mental component subscale showed a similar positive trend (P = 0.077). CHIP participants were more satisfied with their physical health care than TAU patients (P = 0.009), and the CPN were positive about the usefulness/acceptability of the intervention. There were significant within-group improvements in the total numbers of physical health risks, as indicated by the CHIP items (P = 0.005). The findings suggest that it is feasible to conduct a full-scale RCT of the CHIP in future. The CHIP is an intervention that can be used within routine CPN practice, and could result in small–modest improvements in the physical well-being of people with SMI

Rationale, component description and pilot evaluation of a physical health promotion measure for people with mental disorders across Europe

Introduction: The HELPS project aimed at developing a toolkit for the promotion of physical health in people with mental disorders to reduce the substantial excess morbidity and mortality in the target group. Methods: The HELPS toolkit was developed by means of national and international literature reviews, Delphi rounds with mental health experts and focus groups with mental health experts and patients/ residents in 14 European countries. The toolkit was translated into the languages of all participating countries, and usability of toolkit modules was tested. Results: The toolkit consists of several modules addressing diverse somatic health problems, lifestyle, environment issues, patient goals and motivation for health-promotion measures. It aims at empowering people with mental illness and staff to identify physical health risks in their specific contexts and to select the most appropriate modules from a range of health promotion tools. Discussion: The HELPS project used an integrative approach to the development of simple tools for the target population and is available online in 14 European languages. Preliminary evidence suggests that the toolkit can be used in routine care settings and should be put to test in controlled trials to reveal its potential impact

Improving the physical health of people with severe mental illness in a low secure forensic unit: An uncontrolled evaluation study of staff training and physical health care plans

The life expectancy of people with severe mental illnesses is substantially reduced, and monitoring and screening for physical health problems is a key part of addressing this health inequality. Inpatient admission presents a window of opportunity for this health-care activity. The present study was conducted in a forensic mental health unit in England. A personal physical health plan incorporating clearly-presented and easily-understood values and targets for health status in different domains was developed. Alongside this, a brief physical education session was delivered to health-care staff (n = 63). Printed learning materials and pedometers and paper tape measures were also provided. The impact was evaluated by a single-group pretest post-test design; follow-up measures were 4 months' post-intervention. The feasibility and acceptability of personal health plans and associated resources were examined by free-text questionnaire responses. Fifty-seven staff provided measures of attitudes and knowledge before training and implementation of the physical health plans. Matched-pairs analysis indicated a modest but statistically-significant improvement in staff knowledge scores and attitudes to involvement in physical health care. Qualitative feedback indicated limited uptake of the care plans and perceived need for additional support for better adoption of this initiative. Inpatient admission is a key setting for assessing physical health and promoting improved management of health problems. Staff training and purpose-designed personalized care plans hold potential to improve practice and outcomes in this area, but further support for such innovations appears necessary for their uptake in inpatient mental health settings