Edwin Meresh

Does escitalopram reduce neurotoxicity in major depression

A pro-inflammatory state and a dysregulation in the tryptophan/kynurenine pathway have been documented in depression. This study examined whether treatment with the SSRI, escitalopram (ESC), could suppress inflammation and favorably shift metabolites of the kynurenine pathway in patients with major depressive disorder (MDD) within the utilized treatment period. Twenty seven healthy control subjects were included for comparison. Thirty patients were enrolled after completing baseline assessments. They received a 12-week ESC monotherapy. Twenty subjects were completers. Clinical assessments were carried out at each visit using the HAM-D, HAM-A, CGI and BDI rating scales. Blood samples were collected at each assessment and stored until analyzed. Cytokines were analyzed with Randox multiplex assay and tryptophan and kynurenine metabolites were analyzed using HPLC/GCMS. Baseline plasma concentrations of hsCRP, TNFα, IL6 and MCP-1 were significantly higher in patients compared to healthy controls. IL10 trended toward an increase. Baseline plasma IL1β correlated significantly with IL1α, and IL4. Patients showed significant improvement in all outcome measures with a high remission rate. Significant correlations were obtained between specific symptoms and certain biomarkers at baseline but these correlations must be viewed as very preliminary. During ESC treatment concentrations of inflammatory biomarkers did not change except for TNFα that trended lower. Metabolites and ratios of the tryptophan/kynurenine pathway showed reductions of the neurotoxic metabolites, 3-hydroxykynurenine and quinolinic acid, 3-hydroxykynurenine/kynurenine, quinolinic acid/tryptophan, kynurenic acid/quinolinic acid and quinolinic acid/3-hydroxykynurenine. The results indicate that ESC may exert its antidepressant effect in part through inhibition of synthesis of certain neurotoxic kynurenine metabolites and possibly also through reduction of the inflammatory response, although there was no concordance in the time course of changes between antidepressant efficacy and reversal of the pro-inflammatory status.

Vascular Endothelial Growth Factor: A potential diagnostic biomarker for major depression

Despite intense research efforts undertaken by investigators throughout the world over the past half century to identify a specific biomarker for major depressive disorder (MDD), none have so far met the rigorous test of specificity, reliability and reproducibility. Vascular Endothelial Growth Factor (VEGF) has been implicated in the neurotrophic model of depression and several studies have assessed VEGF levels in depressed patients. The results have been discrepant largely due to design and assay differences among studies. The aim of this study was to assess plasma VEGF levels in a cohort of MDD subjects prior to treatment with psychotropic medication and compare them to those of healthy control (HC) subjects. Prospective study participants underwent extensive medical and psychiatric assessments before they were enrolled. Plasma concentrations of VEGF were measured by the technique marketed by Randox Technologies. The mean baseline VEGF for the healthy and depressed groups was 5.91 pg/ml (SD: 3.04) and 10.51 pg/ml (SD: 9.04), respectively, and this difference was statistically significant (p = 0.001). We detected a very low univariate relationship between VEGF and demographic and clinical variables. Using the Optimal Data Analysis a cut score of 6.64 pg/ml for baseline plasma VEGF distinguished depressed from healthy subjects with a 63% overall accuracy. We conclude these results support a role of plasma VEGF as a useful biomarker of depression that can be measured with a routine blood draw at the point of service. The specificity of this potential biomarker must be confirmed in studies that include other psychiatric disease entities.

Central poststroke pain: current diagnosis and treatment.

Abstract Central post-stroke pain syndrome (CPSP) is a debilitating sequel that can follow thalamic sensory stroke. Less well recognized, CPSP follows lateral medullary stroke and parietal cortical stroke and may develop anywhere along the spinothalamic or trigemino-thalamic pathways. Patients describe sharp, stabbing, or burning pain and experience hyperpathia and especially allodynia. Although CPSP was first described over 100 years ago, CPSP is too frequently under-recognized. It is treatable disorder. Pharmacological therapy, magnetic stimulation, and invasive electrical stimulation are reviewed and recommendations made.

Serum BDNF: A Potential Biomarker for Major Depressive Disorder and Antidepressant Response Prediction

Background: The neurotrophin hypothesis of depression emphasizes the role of down-regulation of Brainderived Neurotrophic Factor (BDNF) in the pathophysiology of Major Depressive Disorder (MDD). Patients with MDD may have reduced serum BDNF levels and treatment with antidepressants may stimulate the expression of BDNF resulting in normalization of BDNF after successful treatment. Objective: To determine whether serum BDNF in MDD patients is lower than in healthy control (HC) subjects, whether all MDD patients show lower than normal levels and whether MDD patients with comparatively higher BDNF levels will respond better to antidepressant therapy. Method: Ninety medically healthy outpatients diagnosed with MDD were enrolled in one of two studies. In Study-1 patients were treated with escitalopram and in Study-2 with quetiapine. The main outcome measure was the 17-item Hamilton Depression Scale (HAM-D) scores. Of the 90 enrolled patients 54 had baseline BDNF values. Thirteen HC subjects for whom serum BDNF values were available were included for comparison. Results: Mean baseline serum BDNF did not differ between MDD and HC subjects. When the median BDNF value was used as a “cut score” to subdivide the MDD group into an above median (high) and a below median (low) subgroup, significant differences emerged. Both subgroups differed significantly from the HC mean and from each other. Depressive episodes of greater than 6 months’ duration correlated significantly with higher BDNF levels (p=0.03). Higher BDNF levels predicted a high probability of a positive treatment response (p=0.02) to either of the two pharmacologic agents used. Conclusions: Serum BDNF levels can be higher or lower in MDD subjects when compared to healthy controls. A high baseline BDNF level may predict a positive treatment response to antidepressant drug therapy, suggesting a possible future role of serum BDNF level as a useful biomarker for subtyping MDD and predicting antidepressant treatment response.

Noncardiac chest pain: systematic review of the literature on prognosis

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Serotonin Syndrome Following Septal Myectomy in Association With Fentanyl and Methylene Blue: A Case Report

Abstract The present case report describes a case of serotonin syndrome which developed post septal myectomy in a patient with hypertrophic cardiomyopathy. This case contributes to an emerging awareness of serotonin syndrome in the context of prescribed serotonergic agents, such as SSRIs, and triggered by the addition of fentanyl and methylene blue, particularly in conjunction cardiological procedures. Clinicians should be aware of such interactions which increase the emergence of the serotonin syndrome and the appropriate management of comorbid delirium post-serotonin syndrome.

Review of mini-clinical evaluation exercise (mini-CEX) in a psychiatry clerkship

Background Direct observation of medical students with actual patients is important for the assessment of clinical skills including interviewing and counseling skills. This article describes medical students’ experience of mini-clinical evaluation exercise (mini-CEX) during their clerkship in consultation psychiatry. Materials and methods In our center during inpatient consultation psychiatry clerkship, all rotating students are expected to complete one mini-CEX assessment as part of their clinical training. We conducted retrospective analysis of mini-CEX ratings completed from 2013 to 2016. All evaluations took place at inpatient medical setting in patients admitted with medical conditions and psychiatric comorbidities. Results A total of 113 evaluations were reviewed. The time examiner observed the interaction of a student with the patient was 14.24 minutes (mean), and the time spent in providing feedback to the student was 9.71 minutes. Complexity of problem was rated as low in 0.88% (n=1), moderate in 50.44% (n=57), and high in 48.67% (n=55). Highest ratings were for professionalism, similar to previous reports. Total score calculated by examiner showed no difference by the complexity of the patient; however, we observed a trend in higher counseling score for the high complexity group. Conclusion Mini-CEX assessment during busy clerkship is feasible with good outcomes. Direct observation of medical trainees with actual patients is important for the assessment of performance-based clinical skills. Hospital psychiatry rotation covering various medical and surgical units offers a great opportunity for exposure in patient communication.

Appetite stimulation after surgery in a high nutrition risk adolescent with myotonic dystrophy and depression case report.

In hospitalized patients with chronic medical and surgical conditions, many factors can negatively affect food intake, including psychological factors and anorexia. Appetite disturbance is a common occurrence in patients presenting with complicated medical illnesses. Poor appetite may be a primary symptom directly related to the illness, or it could be attributed to a number of causes comprising fatigue, poor motivation, depression, or all of the above. There is limited research reporting on the association between depression, poor motivation, and lack of appetite contributing to malnutrition. Following is a case report on the management of a severely mal-nourished 17-year-old man admitted to the hospital with myotonic dystrophy, depression, and inflammatory bowel disease. The psychiatry consultation service was consulted to address psychological factors contributing to malnutrition. The patient’s history, laboratory data, the management and hospitalization course of the patient are addressed in this study.