Cyclothymia or Unstable Mood Disorder? A Systematic Treatment Evaluation with Valproic Acid

Cyclic changes in behaviour and mood which do not meet the criteria for bipolar affective disorder have been reported in people with intellectual disability (ID) since the beginning of the twentieth century. The present study postulates a functional disturbance of unstable mood disorder in such cases of an episodic pattern of disturbed behaviour, mood and anxiety. Since symptoms of hypomania or major depression are not observed in these individuals, the unstable mood disorder cannot be regarded as being part of the bipolar spectrum, although it resembles cyclothymia in some aspects. In this pilot study, 28 subjects with ID were treated with valproic acid in dosages leading to a mean plasma concentration of 63 mg L^?1. A marked and sustained improvement was achieved in 68% of subjects in terms of both behaviour stability, and a reduction of symptoms in the mood, anxiety and motor domains.     

Hydrofluoric Acid‐Induced Burns and Life‐Threatening Systemic Poisoning—Favorable Outcome After Hemodialysis

Abstract

Background:?Skin contact with hydrofluoric acid (HF) may cause serious burns and life‐threatening systemic poisoning. The use of hemodialysis in fluoride intoxication after severe dermal exposure to HF has been recommended but not reported. Case report:?A 46‐year‐old previously healthy man had 7% of his body surface exposed to 71% HF. Despite prompt management, with subsequent normalization of the serum electrolytes, recurrent ventricular fibrillation occurred. On clinical suspicion of fluoride‐induced cardiotoxicity, acute hemodialysis was performed. The circulatory status stabilized and the patient fully recovered. High fluoride levels in the urine and serum were confirmed by the laboratory. Discussion:?There is no ultimate proof that the favorable outcome in this case was significantly attributable to the dialysis. However, most reported exposures of this magnitude have resulted in fatal poisoning. As our patient had normal serum electrolytes and no hypoxia or acidosis at the time of his arrhythmias, it was decided that all efforts should be focused on removing fluoride from his blood. The rationale for performing hemodialysis for this purpose is clear, even though such intervention is more obviously indicated in patients with renal failure. Conclusion:?Hemodialysis may be an effective and potentially lifesaving additional treatment for severe exposure to HF when standard management has proven insufficient.     

A Reply to “Carnitine” and “Role of Carnitine in Valproic Acid Toxicity”

Background. Amatoxin‐containing species are responsible for the most severe cases of mushroom poisoning, with high mortality rate. Therefore, this poisoning should be ruled out in all patients presenting gastrointestinal symptoms after wild mushroom ingestion. Objective. To determine sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic efficacy (DE) of urinary amanitin analysis in cases of suspected mushroom poisoning. Methods. All cases of mushroom ingestion referred to a Poison Center during a one‐month period were analyzed. Amanitin measurements were performed by ELISA method (functional least detectable dose 1.5 ng/ml; cut‐off value not clearly established). Gastrointestinal symptoms latency and initial clinical assessment were considered alternative diagnostic tools. Definitive diagnosis was used as the reference standard. Results. Among 61 patients included in the study, amatoxin poisoning was diagnosed in 10 cases. Urine samples were collected 5.5 to 92 hours after mushroom ingestion. Urinary amanitin DE was 91.8%, 93.4%, and 80.3%, based on the cut‐off value considered (1.5, 5.0, and 10.0 ng/ml, respectively). Symptoms latency longer than 6 hours and initial clinical assessment DE were 70.5% and 67.2%, respectively. To identify amatoxin poisoning, initial clinical assessment resulted more sensitive and urinary amanitin analysis more specific. Conclusions. Urinary amanitin analysis is a valuable diagnostic tool and may significantly contribute to the management of suspected mushroom poisoning. At present, the best diagnostic accuracy can be obtained taking advantage of both the high sensitivity and negative predictive value of the clinical assessment performed by an experienced toxicologist, and the high specificity and positive predictive value that characterize urinary amanitin analysis.     

Treatment of Acute Lead Intoxication — Choice of Chelating Agents and Supportive Therapeutic Measures

Abstract

This is a report of an intentionally administered overdose of dimenhydrinate to a 4 month-old infant who subsequently presented with status epilepticus, coma, and life threatening ventricular dysrhythmias. Initial toxicologic analysis of the serum by fluorescence polarization immunoassay was positive for tricyclic antidepressants. Repeat analysis of the serum at 6 hours post ingestion by gas chromatography mass spectrometry analysis defined diphenhydramine 4.8 μg/mL. The infant was managed with IV sodium bicarbonate as utilized in tricyclic antidepressant intoxication. The dysrhythmias resolved and the infant recovered without sequelae.     

Short‐Term Treatment with High‐Dose Atorvastatin Reduces LDL Cholesterol but Shows no Anti‐Inflammatory Effects in Normolipidemic Subjects with Normal CRP Levels

The benefit in reducing cardiovascular risk with statins has been attributed both to cholesterol lowering and pleiotropic effects. These pleiotropic effects are thought to include attenuation of the inflammatory response due to reduced prenylation of proteins in the inflammatory cascade. We conducted studies in normolipidemic subjects to determine if treatment with high‐dose (80 mg) atorvastatin could reduce circulating levels of inflammatory markers. We also determined whether high‐dose atorvastatin affected the inflammatory response of monocytes stimulated with lipopolysaccharide (LPS) ex vivo. We found that treatment with atorvastatin rapidly and significantly reduced plasma low‐density lipoprotein (LDL) cholesterol levels in subjects treated for 2 weeks. However, statin treatment had no discernible effect on plasma levels of the inflammatory markers high‐sensitivity C‐reactive protein (hsCRP), tumor necrosis factor (TNF)‐α, or interleukin (IL‐6) and no effect on the cytokine response of monocytes following ex vivo stimulation with LPS. High‐dose atorvastatin treatment of normolipidemic subjects with normal C‐reactive protein levels has no effect on the inflammatory response assessed by monocyte stimulation with LPS ex vivo despite significant reductions in LDL cholesterol levels. Clin Trans Sci 2010; Volume 3: 140–146     

High Levels of Zinc‐Protoporphyrin Identify Iron Metabolic Abnormalities in Pulmonary Arterial Hypertension

Iron homeostasis influences the development of pulmonary arterial hypertension (PAH) associated with hypoxia or hematologic disorders. To investigate whether severity of idiopathic PAH (IPAH) is impacted by alterations in iron metabolism, we assessed iron metabolic markers, including levels of zinc‐protoporphyrin (Zn‐pp), transferrin receptor, and red blood cell numbers and morphology in IPAH, associated PAH and sleep apnea‐induced pulmonary hypertension patients in comparison to healthy controls and asthmatics. Despite similarly normal measures of iron metabolism, Zn‐pp levels in IPAH and sleep apnea patients were elevated approximately twofold, indicating deficient iron incorporation to form heme and levels were closely related to measures of disease severity. Consistent with high Zn‐pp, PAH patients had increased red cell distribution width (RDW). In an expanded cohort including patients with IPAH and familial disease, the RDW was validated and related to clinical parameters of severity; including pulmonary artery pressures and 6‐minute walk distances. These results reveal an increased prevalence of subclinical functional iron deficiency in primary forms of PAH that is quantitatively related to disease severity. This suggests that altered iron homeostasis influences disease progression and demonstrates the importance of closely monitoring iron status in PAH patients. Clin Trans Sci 2011; Volume 4: 253–258     

The Role of the Nurse‐Physician Leadership Dyad in Implementing the Baby‐Friendly Hospital Initiative

The concept of the nurse‐physician leadership dyad incorporates the expertise of both nurses and physicians as leaders of change within health system environments. The leadership dyad model has been used traditionally in health care administrative settings to manage utilization of resources more effectively. Because the Baby‐Friendly designation requires major cultural shifts in long‐standing maternity care practices, an interdisciplinary approach to implementation is necessary.     

Feasibility of Neoadjuvant Ad‐REIC Gene Therapy in Patients with High‐Risk Localized Prostate Cancer Undergoing Radical Prostatectomy

In a phase I/IIa study of in situ gene therapy using an adenovirus vector carrying the human REIC/Dkk‐3 gene (Ad‐REIC), we assessed the inhibitory effects of cancer recurrence after radical prostatectomy (RP), in patients with high risk localized prostate cancer (PCa). After completing the therapeutic interventions with initially planned three escalating doses of 1.0 × 10¹⁰, 1.0 × 10¹¹, and 1.0 × 10¹² viral particles (VP) in 1.0–1.2 mL (n = 3, 3, and 6), an additional higher dose of 3.0 × 10¹² VP in 3.6 mL (n = 6) was further studied. Patients with recurrence probability of 35% or more within 5 years after RP as calculated by Kattan''s nomogram, were enrolled. They received two ultrasound‐guided intratumoral injections at 2‐week intervals, followed by RP 6 weeks after the second injection. Based on the findings of MRI and biopsy mapping, as a rule, one track injection to the most prominent cancer area was given to initial 12 patients and 3 track injections to multiple cancer areas in additional 6 patients. As compared to the former group, biochemical recurrence‐free survival of the latter showed a significantly favorable outcome. Neoadjuvant Ad‐REIC, mediating simultaneous induction of cancer selective apoptosis and augmentation of antitumor immunity, is a feasible approach in preventing cancer recurrence after RP. (199)     

N‐Acetylcysteine for the Treatment of Clove Oil Induced Fulminant Hepatic Failure: Case Report and Review of the Literature

We present a 3‐month‐old female who developed fulminant hepatic failure after ingesting less than 8 mL of clove oil. Initial treatment involved gastrointestinal decontamination, supportive measures, and admission to hospital. She subsequently developed fulminant hepatic failure and was treated with intravenous N‐acetylcysteine (N‐AC) according to a protocol used for acetaminophen poisoning. Over the next 72h her liver synthetic function and clinical status improved, and she made a complete recovery. Previous reported cases of clove oil toxicity and the potential role of N‐AC therapy are reviewed.     

Lead‐Contaminated Drinking Waters in the Public Schools of Philadelphia

Lead exposure is a preventable environmental health concern. Young children between the ages of 1 to 6 are most susceptible to its clinical effects. This article reports the results of lead level determinations in the drinking water of Philadelphia's public school buildings and remediation efforts aimed at dealing with this public health concern. Methods: Water samples were collected from drinking sources in 292 school buildings in Philadelphia from May 2000 through January 2001. These samples were collected and sent to reference laboratories for determination of lead levels. Results: A total of 42.5% (124) of schools had water lead levels not exceeding the action level of 20 ppb, of which 3.1% had nondetectable levels or levels less than 5 ppb. A total of 28.7% of buildings had water lead levels ranging from 20 to 50 ppb, 11.6% had levels between 50–100 ppb, and 17.1% had water lead levels of 100 ppb or more. Conclusion: A total of 57.4% of Philadelphia's public school buildings had water lead levels exceeding the Environmental Protection Agencies (EPA) action level of 20 ppb, and 28.7% of school buildings had water with mean lead levels in excess of 50 ppb. Depending on the volume of water consumed, drinking water from school buildings may be a significant source of lead exposure for children in their formative years of development. Although Philadelphia's public school buildings were evaluated, lead‐contaminated drinking water in schools is not only an urban concern. School buildings in suburban and rural areas may have similar water lead levels, and testing programs are desirable.     

Circulating oxidized LDL is associated with the occurrence of echolucent plaques in the carotid artery in 61‐year‐old men

Objective. The aim of this study was to elucidate the relationship between the echogenicity of carotid artery plaques and the following risk factors: circulating oxLDL, hsCRP, the metabolic syndrome (MetS), and several of the traditional cardiovascular (CV) risk factors. Material and methods. A cross‐sectional population‐based study of 513 sixty‐one‐year‐old men. The levels of circulating oxLDL were determined in plasma samples by sandwich ELISA utilizing a specific murine monoclonal antibody (mAb‐4E6). High‐sensitivity CRP was measured in plasma by ELISA. Plaque occurrence, size and echogenicity were evaluated from B‐mode ultrasound registrations in the carotid arteries. Plaque echogenicity was assessed based on a four‐graded classification scale. Results. A higher frequency of echolucent carotid plaques was observed with increasing levels of oxLDL and systolic blood pressure (p = 0.008 and p = 0.041, respectively). Subjects with the MetS had a significantly higher frequency of echogenic plaques than subjects without the MetS (p = 0.009). In a multiple logistic regression analysis, oxLDL turned out to be independently associated with echolucent carotid plaques. Conclusions. The occurrence of echolucent carotid plaques was associated with oxLDL and systolic blood pressure, and oxLDL was associated with echolucent carotid plaques independently of systolic blood pressure.     

Treatment of the Shoulder—hand Syndrome

Prophylactic treatment of the shoulder-hand, syndrome following acute myocardial infarction or anginal attack should start while the patient is confined to bed.

Active motion of the arm helps overcome splinting, atrophy and osteoporosis, and may overcome lymphatic and venous stasis. Concomitant use of cortisone lessens pain and spasm.