Treating gout in kidney transplant recipients

OBJECTIVE: To review the etiology, treatment, and preventive strategies of hyperuricemia and gout in kidney transplant recipients. DATA SOURCES: Primary literature was obtained via Medline (1966-June 2003). STUDY SELECTION AND DATA EXTRACTION: Studies evaluating treatment and prevention of hyperuricemia and gout in kidney transplantation were considered for evaluation. English-language studies were selected for inclusion. DATA SYNTHESIS: Approximately 14,000 kidney transplantations were performed in the United States in 2003, and of those transplant recipients, nearly 13% will experience a new onset of gout. The prevalence of hyperuricemia is even greater. There are several mechanisms by which hyperuricemia and gout develop in kidney transplant recipients. Medication-induced hyperuricemia and renal dysfunction are 2 of the more common mechanisms. Prophylactic and treatment options include allopurinol, colchicine, corticosteroids, and, if absolutely necessary, nonsteroidal antiinflammatory drugs. CONCLUSION: It is generally recommended to decide whether the risks of prophylactic therapy and treatment outweigh the benefits. Often, the risk of adverse events associated with agents to treat these ailments tends to outweigh the benefits; therefore, treatment is usually reserved for symptomatic episodes of acute gout. Practitioners must also decide if changes in immunosuppressive regimens may be of benefit on a patient-by-patient basis.     

Evaluation of the Australian Gonococcal Surveillance Programme.

The Australian Gonococcal Surveillance Programme (AGSP) is a laboratory network that monitors the susceptibility of gonococcal isolates to antibiotics used in the treatment of infection. This report evaluates and reports on the simplicity, flexibility, sensitivity, representativeness, timeliness and acceptability of the AGSP. The World Health Organization's (WHO) Questionnaire for Assessment of Antimicrobial Resistance (AMR) National Networks was used in undertaking this evaluation and we report on the questionnaire's usefulness. The evaluation revealed that the AGSP was structurally simple, acceptable, timely and that the data were actively used by the stakeholders. However, the flexibility, representativeness and sensitivity of the AGSP are challenged by the increasing use of molecular based methods to diagnose gonococcal infections, as this is reducing the number of isolates available for testing. Despite this challenge, the AGSP has been able to identify differences in the antimicrobial susceptibility of gonococcal strains circulating in metropolitan and regional communities and the data generated are used to devise or modify standard treatment regimens for gonorrhoea. The functioning of the system can be improved by better availability of data through a dedicated website. Ideally, linkage of AGSP data to notification data would ensure that the AGSP is sensitive to and representative of the changes in gonococcal resistance amongst various sub-populations, although it will increase system complexity. The WHO questionnaire was found to be useful in undertaking the evaluation of the AGSP as it was simple and well-structured. However, the questionnaire needs to be expanded to include benchmarks that guide the assessment process.     

Reproducibility of serial peri-ictal single-photon emission tomography difference images in epilepsy patients undergoing surgical resection

Peri-ictal single-photon emission tomography (SPET) difference images co-registered to magnetic resonance imaging (MRI) visualize regional cerebral blood flow (rCBF) changes and help localize the epileptogenic area in medically refractory epilepsy. Few reports have examined the reproducibility of SPET difference image results. Epilepsy patients having two peri-ictal and at least one interictal SPET scan who later underwent surgical resection were studied. Localization accuracy of peri-ictal SPET difference images results, interictal electroencephalography (EEG), and ictal EEG from the first (seizure 1) and second (seizure 2) seizure, as well as MRI and positron emission tomography (PET) findings, were compared using surgical resection site as the standard. Thirteen patients underwent surgical resection (11 temporal lobe and 2 extratemporal). SPET results from seizure 1 were localized to the surgical site in 12/13 (92%) patients, while SPET results from seizure 2 were localized in 13/13 (100%) patients. All other modalities were less accurate than the SPET results [interictal EEG – seizure 1 6/13 (46%); ictal EEG – seizure 1 5/13 (38%); interictal intracranial EEG – seizure 2 4/9 (44%); ictal intracranial EEG – seizure 2 results 8/9 (89%); MRI 6/13 (46%); PET 9/13 (69%)].SPET results were reproducible in 12/13 (92%) patients.SPET difference images calculated from two independent peri-ictal scans appear to be reproducible and accurately localize the epileptogenic area. While SPET difference images visualize many areas of rCBF change, the quantification of these results along with consideration of injection time improves the diagnostic interpretation of the results. Received 17 July and in revised form 27 September 1999     

Relationship Between Multimorbidity and Health-Related Quality of Life of Patients in Primary Care

Previous studies about the association of multimorbidity and the health-related quality of life (HRQOL) in primary-care patients are limited because of their reliance on simple counts of diseases from a limited list of diseases and their failure to assess the severity of disease. We evaluated the association while taking into account the severity of the medical conditions based on the Cumulative Illness Rating Scale (CIRS) score, and controlling for potential confounders (age, sex, household income, education, self-perception of economic status, number of people living in the same dwelling, and perceived social support). We randomly selected 238 patients to construct quintiles of increasing multimorbidity (CIRS). Patients completed the 36-item Medical Outcomes study questionnaire (SF-36) to evaluate their HRQOL. Applying bivariate and multivariate linear regression analyses, we used the CIRS as either a continuous or a categorical (quintiles) variable. Use of the CIRS revealed a stronger association of HRQOL with multimorbidity than using a simple count of chronic conditions. Physical more than mental health deteriorated with increasing multimorbidity. Perceived social support and self-perception of economic status were significantly related to all scales of the SF-36 (p < 0.05). Increased multimorbidity adversely affected HRQOL in primary-care adult patients, even when confounding variables were controlled for.     

Gender differences in rates of depression among undergraduates: measurement matters

Two studies tested for gender differences in rates of depression among undergraduates using three conceptualizations of depression (mood, syndrome, disorder). The first sample consisted of 325 non-referred undergraduate students, who completed pencil-and-paper measures of depressed mood, depressive syndrome and a depressive disorder analogue. The second sample consisted of 894 undergraduate students seeking counselling services, who participated in clinical intake interviews assessing depressed mood and depressive disorder. Results of analyses provide no evidence of gender differences in rates of depressed mood in either samples or of depressive syndrome in the non-referred sample. However, in both samples, gender differences in rates of depressive disorder were found, with male students more likely than female students to be depressed.     

Cardiac drug-psychotropic drug update

This is an update from the report-Cardiac Drug and Psychotropic Drug Interactions: Significance and Recommendations-published in this journal in November-December 1999. As mentioned in that article there has been an explosion of new drugs both in psychiatry and cardiology without a sufficient understanding of their potential interactions. Also there is a need for methods to update drug interactions on an ongoing basis. This report describes: 1) examples of actual adverse interactions from clinical cases that move beyond some of the hypothesized contraindications included in the 2000 millennium publication; 2) confirmation of previous adverse interactions reported if they strengthen the earlier findings; 3) listing of new drugs, e.g., sildenafil (viagra) now commonly prescribed by psychiatrists and cardiologists; 4) reports explaining and/or refining mechanisms of adverse interactions; and 5) cautions and important associated phenomenon of either a cardiac or a psychotropic drug, e.g., valproic acid and cases of life-threatening pancreatitis. Methods of publicizing the new knowledge of cardiac drug-psychotropic drug interactions, e.g., the Internet and web sites are described.     

Working memory correlates of three symptom clusters in schizophrenia

This study was designed to examine whether discrete working memory deficits underlie positive, negative and disorganised symptoms of schizophrenia. Symptom dimension ratings were assigned to 52 outpatients with schizophrenia (ICD-10 criteria), using items drawn from the Positive and Negative Syndrome Scale (PANSS). Linear regression and correlational analyses were conducted to examine whether symptom dimension scores were related to performance on several tests of working memory function. Severity of negative symptoms correlated with reduced production of words during a verbal fluency task, impaired ability to hold letter and number sequences on-line and manipulate them simultaneously, reduced performance during a dual task, and compromised visuospatial working memory under distraction-free conditions. Severity of disorganisation symptoms correlated with impaired visuospatial working memory under conditions of distraction, failure of inhibition during a verbal fluency task, perseverative responding on a test of set-shifting ability, and impaired ability to judge the veracity of simple declarative statements. Severity of positive symptoms was uncorrelated with performance on any of the measures examined. The present study provides evidence that the positive, negative and disorganised symptom dimensions of the PANSS constitute independent clusters, associated with unique patterns of working memory impairment.     

A recipe for ridding synapses of the ubiquitous AMPA receptor

Getting AMPA receptors into and out of synapses represents an important mechanism for changing synaptic strength, but the signals that target AMPA receptors for removal from the synaptic membrane are incompletely understood. A recent study in Ceanorhabditis elegans suggests that ubiquitination of AMPA receptors is one important signal that targets these receptors for endocytosis.