Effetti Cardiaci e Metabolici della Terapia con Antipsicotici

Gli antipsicotici atipici rappresentano i farmaci di prima scelta per i disturbi dello Spettro Psicotico. Tuttavia, non vi è accordo sui vantaggi, svantaggi e sulla ‘cost-effectiveness’ dei farmaci antipsicotici atipici, se confrontati con i tipici, in particolare per gli effetti metabolici e cardiovascolari sul medio/lungo termine. L’obiettivo dello studio consiste nel valutare, in un campione di pazienti ospedalizzati in un setting naturalistico, i potenziali effetti sul tratto QT/QTc e sui principali parametri metabolici dei farmaci antipsicotici. Sono stati inclusi nello studio 59 pazienti. I criteri d’inclusione erano i seguenti: genere maschile; diagnosi indice all’ospedalizzazione di un disturbo dello Spettro Psicotico (Schizofrenia, Disturbo Schizoaffettivo, Disturbo Bipolare I con sintomi psicotici); comprensione del consenso informato scritto. I criteri di esclusione erano i seguenti: genere femminile; pre-esisenti cardiomiopatie o disturbi del ritmo cardiaco; pre-esistenti condizioni cliniche generali che controindicassero l’utilizzo dei neurolettici; impossibilità a comprendere e sottoscrivere il consenso informato scritto; mancata comprensione della lingua italiana. Il campione è stato suddiviso in due gruppi in funzione del trattamento: 44/59 pazienti con quetiapina (74.6%; dose media/SD: 282.3±254.3 mg) e 15/59 pazienti con antipsicotici tipici (25.4%), clorpromazina (11/15, 73.3s%; dose media/SD: 218.1±103.1 mg) o aloperidolo (4/15, 26.7%; dose media/SD: 2.8±1.3 mg). Non sono stati osservati casi di allungamento dell'intervallo QT/QTc nè differenze statisticamente significative tra i valori di QT/QTc nei confronti per gruppo di trattamento. Non emergono differenze significative per BMI nel confronto tra gruppi. I pazienti obesi costituiscono il 21% del campione, con il 4.3% in classe di obesità III. I pazienti con valori di colesterolo≥200 mg/dlsono un gruppo ridotto (10.1%; n=6), 5/6 in trattamento con quetiapina. L’alterazione dei trigliceridi è frequente (36.5%; n=19), ma non si sono riscontrate differenze tra i gruppi di trattamento. Le HDL sono alterate in 2 pazienti (3.8%) in trattamento con quetiapina. Le LDL sono alterate in 8 pazienti (8/59; 13.5%), 7/8 (87.5%) in trattamento con quetiapina. I risultati di questo studio sono in linea con i dati della letteratura sull’associazione tra disturbi dello Spettro Psicotico e aumento del BMI. La valutazione del QT/QTc ha mostrato un basso rischio di LQTS. L’indagine dell’assetto metabolico, insieme al monitoraggio ECG, si confermano aspetti cardine nella gestione del paziente con disturbi dello Spettro Psicotico

Multiple vertebral hemangiomas of the thoracic spine with atypical radiological features and aggressive behavior causing myelopathy: A case report

Abstract Background Vertebral Haemangiomas (VHs) are frequent and generally asymptomatic benign tumors, involving the spine, usually incidentally found on computed tomography and magnetic resonance. Despite being usually asymptomatic and quiescent lesions, VHs can occasionally manifest aggressive features, leading to clinical manifestations such as back pain and neurological deficits. Case report. We report a case of a 54-year-old man, presented with 5 months history of pain, associated with lower limbs paraesthesia and weakness, gait disturbance and episodes of accidental falls. Radiological evaluation by spine pre- and post-contrast MRI indicated multiple vertebral hypervascular lesions, compatible with haemangiomas, involving from T3 to T11 levels, showing several different features (typical and atypical); aggressive haemangioma radiological pattern may be valuable at T3 and T4 vertebras. A thoracic spine pre- and post-contrast computed tomography confirmed the radiological diagnosis of multiple aggressive haemangiomas. Discussion Aggressive VH consists in a very rare subset of vertebral haemangiomas characterized by a greater tendency in being symptomatic. They may show atypical radiological features, that make their diagnosis very complex. In the recent years, many strategies for treatment of symptomatic or aggressive VHs have been developed, but the optimal treatment strategy is still controversial. Conclusion Although aggressive VHs being extremely rare, recognizing radiological features of these lesions is mandatory to achieve a correct diagnosis and appropriate therapeutic targets

ADC Benchmark Range for Correct Diagnosis of Primary and Recurrent Middle Ear Cholesteatoma

Objectives. Magnetic resonance imaging (MRI) and in particular diffusion-weighted imaging (DWI) have been broadly proven to be the reference imaging method to discriminate between cholesteatoma and noncholesteatomatous middle ear lesions, especially when high tissue specificity is required. The aim of this study is to define a range of apparent diffusion coefficient (ADC) values within which the diagnosis of cholesteatoma is almost certain. Methods. The study was retrospectively conducted on a cohort of 124 patients. All patients underwent first- or second-look surgery because primary or secondary acquired cholesteatoma was clinically suspected; they all had preoperative MRI examination 15 days before surgery, including DWI from which the ADC maps were calculated. Results. Average ADC value for cholesteatomas was 859,4 × 10−6 mm2/s (range 1545 × 10−6 mm2/s; IQR = 362 × 10−6 mm2/s; σ = 276,3 × 10−6 mm2/s), while for noncholesteatomatous inflammatory lesions, it was 2216,3 × 10−6 mm2/s (range 1015 × 10−6 mm2/s; IQR = 372,75 × 10−6 mm2/s; σ = 225,6 × 10−6 mm2/s). Interobserver agreement with Fleiss’ Kappa statistics was 0,96. No overlap between two groups’ range of values was found and the difference was statistically significant for p<0.0001. Conclusions. We propose an interval of ADC values that should represent an appropriate benchmark range for a correct differentiation between cholesteatoma and granulation tissue or fibrosis of noncholesteatomatous inflammatory lesions

Skull Base Fungal Osteomyelitis: A Case Report and Review of the Literature

Skull base osteomyelitis (SBO) is an invasive infection refractory to therapy, closely linked with malignant otitis externa (MOE). It is characterized by a mild clinical presentation that can delay cross-sectional imaging considered as the key to revealing it. Skull base osteomyelitis typically affects elderly diabetics and immunocompromised patients (>70 years). It most commonly has an otogenic origin due to an extension of MOE. The prognosis can be very poor without the administration of adequate and timely therapy at an early disease stage. Nowadays, Pseudomonas aeruginosa remains the most common pathogen associated with SBO. Fungi are a rare cause of MOE. This report documents a rare case of otogenic SBO caused by Candida parapsilosis in a diabetic patient, with persistent otologic symptoms as clinical onset and resistance to medical treatment. Fungal MOE has more subtle symptoms and is more aggressive than its bacterial counterpart. When MOE is resistant to antibacterial drugs, this should raise the suspicion of a fungal etiology of MOE. The current guidelines do not exhaustively describe the diagnosis, antifungal drugs of choice, and optimum duration of treatment. The description of these rare clinical cases should help with the multidisciplinary management of this disease in order to optimize the diagnosis and therapeutic protocol

Bipolar disorder in the elderly: clinical implications of late onset and somatic comorbidity

ABSTRACT Background: Although elderly represents more than 25% of all the bipolar disorder (BD) patients, literature about BD in old age is still limited. Method: A retrospective chart review was conducted to investigate the course of BD in late life. One hundred patients ≥ 65 years were selected according the following criteria: 1) the diagnosis of a depressive episode according to the International Classification of Disease, Tenth Edition (ICD-10), 2) a Clinical Global Impression – Severity of illness ≥ 4 (i.e. “moderately ill” or above) and 3) a follow-up duration ≥ 18 months. The subgroups of patients with a definite diagnosis of BD at the end of the observational period (N = 60) were subdivided according to age at onset terciles in very late age at onset (VLOBD), late (LOBD) and regular age at onset of BD (ROBD), then we compared follow-up morbidity differences between the different groups. In addition, we investigated the implications of somatic comorbidities on the course of the BD. Results: From the index episode to the end of follow-up, 17 patients reported a diagnostic changes from unipolar depression to BD spectrum. Interestingly, both groups of patients with VLOBD and ROBD spent significantly more time with symptoms and depressive symptoms compared with the LOBD group. The VLOBD patients had a higher percentage of time spent in major episodes in comparison to the LOBD group and a higher percentage of time spent both with (hypo)manic symptoms and (hypo)manic episodes in comparison to the other two groups. Both time with symptoms and time with depressive symptoms were significantly positively associated with obesity. Conversely, diabetes mellitus type 2 was found to be significantly positively associated with time with (hypo)manic symptoms. Conclusion: VLOBD and somatic metabolic comorbidities specifically and differentially increase BD morbidity in the very old age

Psychiatric Symptoms in Patients with Cerebral Endometriosis: A Case Report and Literature Review

Endometriosis is a systemic medical condition characterized by endometrial tissue that is abnormally implanted in extrauterine sites, including the central nervous system. In this article, we reported the case of a patient with presumed cerebral endometriosis who was diagnosed with bipolar disorder and panic disorder and systematically reviewed the literature for previously reported neuropsychiatric symptoms in patients with cerebral and cerebellar endometriosis. The PubMed, Scopus, and Web of Science bibliographic databases were searched according to the PRISMA guidelines. Seven previous case reports were found and described. While neurological disturbances dominated the clinical picture in the cases retrieved from the literature, our patient represented the first case to show both neurological and psychiatric manifestations. Atypical features of bipolar disorder including chronic mood instability, mixed episodes, and excitatory interepisodic symptoms were highlighted. During the neuropsychological evaluation, a dysexecutive profile consistent with frontal lobe pathology was evidenced. We hypothesized that the course and features of the illness were largely influenced by the presence of documented brain lesions compatible with endometrial implants, especially in the frontal region. Accordingly, patients with endometriosis who exhibit neurological as well as mental symptoms should be investigated for cerebral lesions

Mild behavioral impairment: Presentation of the diagnostic criteria and the Italian version of the MBI-Checklist

SUMMARY. Neuropsychiatric symptoms (NPS) are common in the prodromal stage of dementia and can precede the onset of cognitive impairment. The presence of NPS in cognitively normal patients or in patients with Mild Cognitive Impairment (MCI) is associated with an increased risk of progression along the neurodegenerative process. The need to identify, in the early stages of the disease, the population at risk of cognitive decline has led to the formulation of the concept of Mild Behavioral Impairment (MBI). This neurobehavioral syndrome is characterized by late-onset sustained psychiatric symptoms, in patients without cognitive deficits or in those with MCI, identifying a condition associated with an increased probability of conversion into dementia. MBI represents the neurobehavioral axis of pre-dementia risk states, as a complement to the neurocognitive axis of MCI. For some, MBI may be the initial manifestation of neurodegenerative disease, observed before cognitive impairment is apparent. The Mild Behavioral Impairment-Checklist (MBI-C) was developed on the basis of the MBI diagnostic criteria, established by the International Society to Advance Alzheimer’s Research and Treatment (ISTAART). The MBI-C allows to identify, in a standardized way, patients with MBI and to follow the course of their neurodegenerative disease. This article describes the creation of the MBI-C scale and presents its Italian version

Risk of conversion to bipolar disorder in patients with late-onset major depression

To evaluate the impact of age at onset on late-life depression course and on risk of conversion to bipolar disorder (BD). A retrospective chart review of 100 elderly patients (age ≥ 65 years) diagnosed with a moderate-to-severe depressive episode and followed up for at least 18 months was conducted. Among patients affected by major depressive disorder ( N = 57), follow-up morbidity differences between those with typical onset depression (TOD) (&lt;60 years) and those with late-onset depression (LOD) (≥60 years) were investigated using Wilcoxon rank-sum test and Cox proportional hazard model. Patients belonging to the LOD group had a significantly lower percentage of follow-up time spent with depressive symptoms compared with patients with TOD ( r = 0.36; P = 0.006), but significantly more time spent with (hypo)manic episodes ( r = -0.31; P = 0.021). Moreover, LOD was significantly associated with a faster conversion to BD (hazard ratio = 3.05; P = 0.037). Depression first emerging in late life may represent an unstable condition with a high risk to convert to BD. Given the potential clinical implications, further studies on the course of LOD are required

Revisiting stimulant use for emotional dysregulation in attention-deficit/hyperactivity disorder (ADHD)

IntroductionEmotional dysregulation (ED) symptoms are present in a considerable portion of patients with attention-deficit/hyperactivity disorder (ADHD). In recent years, an increasing number of studies investigated the effects of stimulant medications on ED in patients with ADHD.Areas coveredA narrative review of the literature on stimulant treatment for ED is provided, including controlled and observational clinical studies conducted on pediatric and adult samples and neurobiological investigations. Positive effects of stimulants on irritability have been demonstrated in children. Comorbidity with disruptive behavior disorders (DBD) and disruptive mood dysregulation disorder does not prevent stimulant effectiveness. Methylphenidate has also been found to reduce temper problems, affective instability, and emotional over-reactivity in adults with ADHD, although with variable effect sizes. A variety of adverse emotional effects have been reported, especially at high doses and in special populations. However, several possible confounders of treatment-emergent ED have been highlighted. Finally, according to neuroimaging studies, stimulants may mitigate emotional processing anomalies associated with ADHD.Expert opinionThe findings are consistent with models including ED within the core features of ADHD. Stimulant treatment should be prioritized over antipsychotics in ADHD-DBD. It remains to be elucidated whether other medications may be more effective in specific populations with ADHD and/or ED

Neuroimaging in meningiomas: old tips and new tricks

Meningiomas are the most common neoplasm of the central nervous system. Usually benign and generally discovered incidentally at imaging, meningiomas can also be responsible for severe neurological symptoms and deficits, with potentially high morbidity and non-negligible mortality. Therefore, neuroimaging plays a crucial role in meningiomas diagnosis, therapeutic planning, and long-term surveillance, for early detection of both recurrence in treated patients and disease progression in untreated ones. Here, we review conventional findings in meningiomas’ imaging, review the role for advanced diagnostic techniques, and offer an overview on possible future neuroimaging applications