Mirtazapine in suicidal Huntington's disease TO THE EDITOR: Huntington's disease (HD) is a progressive neurodegenerative disorder, whose major progressive clinical features are chorea, dementia, and psychiatric disturbances such as depression or psychotic episodes. Depression is said to be frequent in HD, and, in various studies, prevalence has varied from 9% to 44%. 1 We report the case of a woman whose severe depression and suicidal ideations secondary to HD were successfully treated with mirtazapine. Case Report. A 32-year-old woman with HD (42 cytosine-adenine-guanine repeats) of 6 years' duration was hospitalized due to a suicide attempt by jumping out of the window from the second floor. Before this suicide attempt, she had been treated with olanzapine (for the choreatic movement disorder) and riluzole. The woman developed a severe depressive episode at home, not adequately realized by her husband. The patient had known about the positive genetic test results for HD for 2 years, and the depression seemed to be unrelated neither to this fact nor to any other exogenic reason. Besides fracturing both calcaneus and lumbar vertebral body III, the patient presented in a depressive stupor. She was oriented and able to follow commands and speak, but did not answer with more than a word; her thoughts monotonously revolved around suicide. After admission, she was treated with mirtazapine 30 mg/d, which had to be increased to 90 mg/d in the next week. However, due to this medication the mood improved significantly in the next few weeks, and the patient started to speak after 5 days of treatment; suicidal thoughts disappeared after 2 weeks of treatment. We reduced mirtazapine to 60 mg/d after 2 months and to 30 mg/d after 9 months. The woman is seen in our outpatient clinic every month and has remained in a stable mood for >1 year. Discussion. Depression in HD often precedes the onset of neurologic symptoms and responds to antidepressant medication, but may not be interpreted as a merely psychological response to the development of the disease. 2 Thus, depression seems to result from neuropathologic changes. It was hypothesized that the neuronal loss in the medial anterior caudate is responsible for both the neurologic and emotional symptoms. 1 In his original paper, George Huntington 3 himself drew attention to "that form of insanity which leads to suicide." In fact, several studies 1,4-6 have supported this statement by showing high suicide rates in HD. Six percent of deaths among affected persons result from suicide, and 28% of patients with HD attempted suicide at least once. 4 Factors that increase the risk of suicide are having no offspring, being unmarried, having a family history of suicide, living alone, endogenous depression, and having no contact with others who have HD. 5 Today, there are only case reports available on the treatment of depression from HD, and, moreover, there is no treatment recommendation for suicidal HD patients. Mirtazapine, a noradrenergic and specific serotonergic antidepressant, was s...

A 51-year woman with a seropositive rheumatoid arthritis (RA) developed antiLa/SSB antibodies and erythematosquamous lesions on her upper back. The histological diagnosis was subacute cutaneous lupus erythematosus (SCLE) (papulosquamous form). There was no indication or a drug-induced SCLE. The concurrence of RA and SCLE seems to be rare. We review the clinical, serologic and immunogenetic features in these patients with coexistent RA and SCLE.

Background:Insights from patients are important for health care planningObjectives:In this study we describe the perception of patients with 4 different chronic conditions with health care in Spain through the IEXPAC scale (“Instrument to Evaluate the EXperience of PAtients with Chronic diseases”), a scale developed and validated in Spain.Methods:The IEXPAC scale (http://www.iemac.es/iexpac/) was developed and validated in Spain by health care professional and social organizations, experts in quality of health care and chronic patients. The scale is structured in 12 items with Likert responses from “always” to “never”, yields a score from 0 (worst experience) to 10 (best experience), and identifies aspects of health care needing improvement. A survey was handed to patients needing care in at least two different levels (i.e. primary care and hospital) and with one of the following chronic conditions A) Rheumatic diseases, B) Inflammatory bowel disease (IBD), C) Human immunodeficiency virus infection (HIV) and D) Diabetes mellitus (DM) plus cardiovascular or renal chronic disease. Patients completed the survey at home and responded by pre-paid mail.Results:2474 patients received the survey, 1618 (65.4%) returned it (359 with rheumatic disease, 341 with IBD, 467 with HIV infection, 451 with DM, mean age 56 years, 41% women). Only 6.1% were affiliated to a patients association. Patients declared a median of 8 visits (IQR 25–75: 4–15) to primary care or specialty clinics in the last year and 29% had visited an emergency room. In the last 3 years 48% had been hospitalized. Up to 61% reported to search for information on diseases, therapies, lifestyle or diet in webpages, general or social media. Responses to the IEXPAC items (percentages that responded “mostly” + “always” to each item) are displayed in the table. In general, these % were higher in HIV patients, which represents a better experience with health care. In some items, patients with rheumatic diseases scored lower (table 1). Mean IEXPAC score was 6.0 (SD1.8) and was higher in HIV patients (table 1). Worst scores were seen in items related to access or guidance for getting reliable information on health and on social resources, contact with other patients and follow-up after hospital discharge.Conclusions:The IEXPAC questionnaire identified areas of improvement in chronic patients health care in Spain, especially those related with access to reliable information and services, interaction with other patients and continuity of health care after hospital discharge. Patients with HIV infection scored higher, maybe consequence of a more personalized care. In several items, patients with rheumatic diseases scored lowerAcknowledgements:Funded by Merck Sharp & Dohme, Spain, with endorsement of 4 patients associations: CONARTRITIS (patients with rheumatid diseases), ACCU (patients with IBD), SEISIDA (HIV multidisciplinary group), FEDE (patients with DM)Disclosure of Interest:None declared

Background:Improving quality of life is a goal in the treatment of patients with rheumatic diseases.Objectives:In this work, we describe the self-assessment of quality of life made by patients with rheumatic diseases and with other chronic diseases through an anonymous survey in the context of a wider project on quality of care.Methods:In the context of a quality of care project, focused in the perceptions of chronic patients with health care in Spain (assessed with the IEXPAC scale (“Instrument to Evaluate the EXperience of PAtients with Chronic diseases”, http://www.iemac.es/iexpac/), a survey was handed patients with 4 different profiles of chronic diseases needing care in at least two different levels (i.e. hospital clinic and primary care): A) Patients with rheumatic diseases (rheumatoid arthritis or spondyloarthritis) from hospital clinics, B) Inflammatory bowel disease (IBD) patients from hospital clinics, C) Patients with human immunodeficiency virus (HIV) infection from HIV units and D) Patients with diabetes mellitus (DM) plus cardiovascular or renal chronic disease from primary care or endocrinology clinics. Patients were handed the survey and completed the survey at home, returning it by pre-paid mail. As part of the survey, they completed the quality of life questionnaire EQ-5D-5L.Results:2474 patients received the survey, 1618 (65.4%) returned it (359 with rheumatic disease [mean age 55 years, 63% women], 341 with IBD [mean age 47 years, 48% women], 467 with HIV infection [mean age 52 years, 27% women], 451 with DM [mean age 70 years, 32% women). Patients with rheumatic diseases more frequently described moderate or severe problems with mobility, self-care and usual activities and reported more pain (table 1). Patients with rheumatic disease and IBD more frequently reported anxiety or depression (table 1). Scores in the Visual Analogic Scale “Your Health Today” (from 0 worst health to 100 best health) were lower in patients with rheumatic diseases (mean score 61.9 [SD 19.5]) than in patients with IBD (68.8 [17.8]), HIV infection (73.3 [19.1]) or DM (67.0 [17.1]), all multiple comparison tests rheumatic disease versus other, p<0,001).Conclusions:Self-evaluation by patients showed that quality of life of patients with rheumatic diseases (rheumatoid arthritis, spondyloarthritis) is worse that that of patients with IBD, HIV infection or DM. Improving quality of life is an essential goal to achieve in the care of patients with these rheumatic diseases.Acknowledgements:Funded by Merck Sharp & Dohme of Spain and endorsed by 4 patients associations (CONARTRITIS: patients with arthritis; ACCU: patients with Crohn’s disease and ulcerative colitis; SEISIDA: AIDS multidiscipline group, FEDE: patients with diabetes mellitus).Disclosure of Interest:None declared

BackgroundNon-adherence to medication may lead to poorer clinical outcomes and should be prevented.ObjectivesWe describe the frequency of non-adherence behaviors in patients with rheumatic diseases and its relationship to potentially modifiable variables.MethodsData were obtained through an anonymous survey handed to patients by physicians or nurses from 25 rheumatology clinics from Spain. Patients completed the survey anonymously at home and returned it by pre-paid post mail. Five different non-adherence behaviors were defined. Co-variables analyzed were patients’ demographics, medication characteristics, experience with healthcare (assessed with IEXPAC “Instrument to Evaluate the EXperience of PAtients with Chronic diseases” scoring 0 [worst] to 10 [best experience]), and beliefs in medicines (Beliefs About Medicines Questionnaire [BMQ], composed of a necessity and a concerns subscales and scoring -20 [weaker] to +20 [stronger beliefs]). Variables associated to non-adherence were studied with a multivariate logistic regression model.ResultsThe survey was handed to 625 patients with rheumatic diseases, of which 336 (53.8%) returned it with the necessary data completed (mean age 55 [14] years, 64% women). Of them, 188 (56.0%) described at least one non-adherence behavior. The frequencies of the specific non-adherence behaviors were: 1) Forgetfulness in taking medication: 28.6%; 2) Taking medication at unscheduled hours: 5.6%; 3) Stopping medication when feeling well: 10.1%; 4) Stopping medication when feeling sick: 33.0% and 5) Stopping medication after reading the patients’ information leaflet: 11.5%. The frequency of at least one non-adherence behavior was similar by age, gender, educational level, working status or by number of medicines. It was slightly higher in patients needing to take their medication 3-4 times a day (63.2%) versus 1-2 times a day (52.4%, p= 0.089). IEXPAC scores were similar in patients with or without non-adherence behaviors (5.5 [2.0] in both groups, p= 0.960). BMQ overall score was lower in patients with non-adherence behaviors (4.3 versus 6.5 in those without non-adherence behaviors, p= 0.001). The frequency of non-adherence behaviors did not differ by quartiles of IEXPAC score, but it was higher in patients with lower BMQ score (Q1: 59.5%, Q2: 65.9%, Q3: 54.3%, Q4: 52.0%, p-trend = 0.014). The multivariate model (table) confirmed a relationship of non-adherence behaviors with lower BMQ beliefs scores.ConclusionNon-adherence behaviors are frequent in patients with rheumatic diseases and are mainly associated to patients’ beliefs in their medications (assessed with BMQ). This is an important aspect that can be addressed by clinical teams to improve adherence and clinical outcomes.Table 1Multivariate analysis. Factors associated to non-adherence behaviors of patients with rheumatic diseases. Acknowledgement: Funded by Merck Sharp & Dohme of Spain and endorsed by 4 patients associations: ACCU, CONARTRITIS, SEISIDA, FEDE.Disclosure of InterestsMaría L. García Vivar: None declared, Javier d...