Psychiatric Morbidity in Dependent Z-Drugs and Benzodiazepine Users

Zolpidem/zopiclone (Z-drugs) and benzodiazepines (BDZs) have different profiles of comorbidity, but studies have seldom explored these differences. This study examined psychiatric comorbidity in patients dependent on Z-drugs or BDZs attending substance abuse clinics in Hong Kong. In this retrospective chart review, the medical records of 207 patients (117 on Z-drugs and 90 on BDZs) treated between January 2008 and August 2012 were analysed. Demographic data, patterns of substance misuse and comorbid psychiatric diagnoses were recorded. Patients dependent on Z-drugs were younger (40.5?±?10.4 vs. 46.8?±?11.6; p?<?0.001), had an earlier age of onset of drug misuse (p?=?0.047) and were more likely to currently use cough syrup (29.5?±?12.1 vs. 33.6?±?14.5; p?=?0.009) than the BDZs dependent patients. Overall, the Z-drugs and BDZs groups had a similar frequency of comorbid psychotic disorders, mood disorders and anxiety disorders. Mood disorders were the most common comorbid psychiatric disorders. The zopiclone group had a significantly higher percentage of psychotic disorders than the zolpidem group (25.5 % vs. 0; p?=?0.022). To summarize, patients with Z-drugs or BDZs dependence have similar psychiatric comorbidities, with depressive disorder the most common comorbidity. Zopiclone is more likely to be associated with psychotic disorders than zolpidem.     

The effects of neoadjuvant chemoradiation on pTNM staging and its prognostic significance in esophageal cancer

For esophageal cancer, it is not clear if pathologic TNM staging after chemoradiation and resection will have the same prognostic significance compared with patients who undergo resection only. From 1995 to 2004, prospectively collected data from 279 patients with intrathoracic squamous cell cancers were analyzed. Patients were given chemoradiation either as part of a randomized trial comparing neoadjuvant chemoradiation with surgical resection alone, or because of advanced disease at presentation. One hundred seventy patients had surgical resection only (surgery), and 109 had neoadjuvant chemoradiation (CRT plus surgery). In the surgery group, pT1, 2, 3, and 4 disease was found in 15, 17, 104, and 34 patients, respectively; their respective pN1 rates were 13.3%, 29.4%, 57.7%, and 64.7%, P<0.01. In CRT plus surgery, pT0, T1, 2, 3, and 4 were found in 48, 12, 23, 21, and 5 patients, respectively; their respective pN1 rates were 31.3%, 16.7%, 21.7%, 52.4%, and 20%, P=0.44. Logistic regression analysis of factors predictive of pN1 showed that pT stage correlated with pN1 status (P=0.005) in the surgery group, but not for the CRT plus surgery group. Cox regression analysis demonstrated that in the surgery group, pT, pN, and R category, and overall pTNM stage, were independent prognostic factors, whereas pN, R category, and gender were identified as relevant for CRT plus surgery. After chemoradiation, pT and overall pTNM stage groupings were not as clearly prognostic as in patients without prior therapy. Nodal status remains an important prognostic factor. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006 (oral presentation).     

Anogenital HIV RNA in Thai men who have sex with men in Bangkok during acute HIV infection and after randomization to standard vs. intensified antiretroviral regimens

Introduction

HIV transmission risk is highest during acute HIV infection (AHI). We evaluated HIV RNA in the anogenital compartment in men who have sex with men (MSM) during AHI and compared time to undetectable HIV RNA after three-drug versus five-drug antiretroviral therapy (ART) to understand risk for onward HIV transmission.

Methods

MSM with AHI (n=54) had blood, seminal plasma and anal lavage collected for HIV RNA at baseline, days 3 and 7, and weeks 2, 4, 12 and 24. Data were compared between AHI stages: 1 (fourth-generation antigen-antibody combo immunoassay [IA]–, third-generation IA–, n=15), 2 (fourth-generation IA+, third-generation IA–, n=9) and 3 (fourth-generation IA+, third-generation IA+, western blot–/indeterminate, n=30) by randomization to five-drug (tenofovir+emtricitabine+efavirenz+raltegravir+maraviroc, n=18) versus three-drug (tenofovir+emtricitabine+efavirenz, n=18) regimens.

Results

Mean age was 29 years and mean duration since HIV exposure was 15.4 days. Mean baseline HIV RNA was 5.5 in blood, 3.9 in seminal plasma and 2.6 log₁₀ copies/ml in anal lavage (p<0.001). Blood and seminal plasma HIV RNA were higher in AHI Stage 3 compared to Stage 1 (p<0.01). Median time from ART initiation to HIV RNA <50 copies/ml was 60 days in blood, 15 days in seminal plasma and three days in anal lavage. Compared with the three-drug ART, the five-drug ART had a shorter time to HIV RNA <1500 copies/ml in blood (15 vs. 29 days, p=0.005) and <50 copies/ml in seminal plasma (13 vs. 24 days, p=0.048).

Conclusions

Among MSM with AHI, HIV RNA was highest in blood, followed by seminal plasma and anal lavage. ART rapidly reduced HIV RNA in all compartments, with regimen intensified by raltegravir and maraviroc showing faster HIV RNA reductions in blood and seminal plasma.     

Long-term sensorineural hearing deficit following radiotherapy in patients suffering from nasopharyngeal carcinoma: A prospective study.

BACKGROUND: This was a prospective study to evaluate the effect of radical external irradiation on inner ear function after treatment of nasopharyngeal carcinoma. METHODS: Pure tone audiograms were performed at regular intervals before, after, and up to 4.5 years following completion of radiotherapy. RESULTS: Two hundred ninety-four patients (526 ears) were included. Within 3 months after radiotherapy, deterioration of bone conduction threshold at 4 kHz and pure tone average (average of 0.5 kHz, 1 kHz, and 2 kHz) were noted in 164 ears (31%) and 75 ears (14%), respectively. Patients older than 50 years and ears with threshold below 60 dB at 4 kHz before radiotherapy were significant factors (p < 0.01 and p < 0. 001) associated with a 4 kHz loss. In 40% of these ears, recovery was evident at 2 years. With follow-up for 4.5 years, the probability of significant threshold deterioration increased with time. CONCLUSION: Sensorineural hearing loss started soon after radiotherapy. Early changes could be reversible while the probability of persistent hearing loss continued to increase.     

Outcome of first-episode acute and transient psychotic disorder in Hong Kong Chinese: a 20-year retrospective follow-up study

Background: ‘Acute and transient psychotic disorder’ (ATPD) is a category in ICD-10 marked by psychosis with acute onset and early remission. It remains relatively under-researched, despite controversies over its nosological status in the current classification system.

Aims: (1) To assess the changes in diagnosis over time in patients initially diagnosed as ATPD. (2) To identify factors predicting changes in diagnosis, and compare the long-term outcomes of various patterns of diagnostic shift. (3) To make recommendations on the classification and treatment of ATPD based on the findings of the study.

Methods: This was a retrospective longitudinal study based on review of medical records of patients first admitted to a regional hospital in Hong Kong for ATPD during the period from 1990–2000.

Results: Of the 87 subjects initially diagnosed as ATPD, 64.4% had their diagnoses revised over an average of 20 years, mostly to bipolar disorder and schizophrenia. Among those with diagnosis of ATPD unchanged, 54.8% had one single episode, while the remaining 45.2% had recurrence. Subjects with diagnostic shift had significantly younger age of onset, more first-degree relatives with a history of mental illness, and more subsequent psychiatric admissions.

Conclusions: ATPD is likely a composite category consisting of clinically distinct outcome groups, for which further research is warranted to identify diagnostic features that distinguish them at initial presentation and revise the current nosological status of ATPD. Long-term follow-up, judicial use of antipsychotics, and education on prognosis are of paramount importance in managing patients diagnosed with ATPD.     

Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting

Aims and objectives. To assess and compare the predictive validity of the modified Braden and Braden scales and to identify which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute care setting. Background. Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed. Design. A prospective cohort study. Method. A total of 197 subjects in a 106‐bed orthopaedic department of an acute care hospital in Hong Kong were assessed for their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected. Results. Out of 197 subjects, 18 patients (9·1%) developed pressure ulcers. The area under the receiver operating characteristic curve for the modified Braden scale was 0·736 and for the Braden scale was 0·648. The modified Braden cut‐off score of 19 showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = ?1·544, OR=0·214, p = 0·016), body build for height (Beta = ?0·755, OR = 0·470, p = 0·030) and skin type (Beta = ?1·527, OR = 0·217, p = 0·002) were significantly predictive of pressure ulcer development. Conclusion. The modified Braden scale is more predictive of pressure ulcer development than the Braden scale. Relevance to clinical practice. The modified Braden scale can be adopted for predicting pressure ulcer development among orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.     

Intrathecal chemotherapy for hematologic malignancies: drugs and toxicities

Intrathecal (IT) chemotherapy is an important component of the prophylaxis or treatment of hematologic malignancies in the central nervous system (CNS), especially in patients with acute lymphoblastic leukemia and aggressive lymphomas. Different regimens of IT chemotherapies have been formulated, often in conjunction with systemic high-dose chemotherapy leading to penetration of the drugs into the cerebrospinal fluid (CSF). The three commonest IT drugs are methotrexate, cytosine arabinoside (Ara-C), and corticosteroids. The CSF half-lives of methotrexate and Ara-C are much prolonged, a factor to be considered if these drugs are also administered systemically in high doses. Neurotoxicities attributed to IT chemotherapy have been reported, including spinal cord lesions, seizures, and encephalopathy. Spinal cord lesions, manifesting as tetraplegia, paraplegia, and cauda equina syndrome, are the commonest neurotoxicity. It is mostly related to combined IT methotrexate and Ara-C, or Ara-C as the sole IT agent when given at high doses or as a slow-release preparation. Cord lesions rarely recover and patients are left with motor deficits, bowel and urinary disabilities. Seizures and encephalopathy are reported in relatively fewer patients, with variable manifestations and prognosis. Knowledge of the pharmacokinetics, dosing schedules and potential toxicities of IT chemotherapeutic drugs is important in the design of CNS prophylaxis and treatment in hematologic malignancies.     

Diffusion-weighted imaging and proton magnetic resonance spectroscopy in perinatal hypoxic-ischemic encephalopathy: association with neuromotor outcome at 18 months of age

We evaluated early diffusion-weighted imaging findings, the quantitative apparent diffusion coefficient, and magnetic resonance spectroscopy (the presence of lactate and ratios of N-acetylaspartate to total creatine and choline to total creatine) in the prediction of the 18-month neuromotor outcome of term newborns with hypoxic-ischemic encephalopathy. Conventional T1- and T2-weighted and diffusion-weighted imaging was performed in 20 asphyxiated term newborns, with additional basal ganglia magnetic resonance spectroscopy in 15 newborns between 2 and 18 days of life (mean 7.3 days). Neuromotor outcome was dichotomized into normal and abnormal for statistical analysis. Statistically significant differences in the ratios of N-acetylaspartate to total creatine, but not apparent diffusion coefficient values and ratios of choline to total creatine, were found between infants with a normal and an abnormal outcome (Mann-Whitney U-test, P = .010). There was a significant association between the presence of a lactate peak and an abnormal outcome (chi-square test, P = .017). The presence of a lactate peak for predicting an abnormal outcome had a sensitivity of 100% and a specificity of 80%, and the odds ratio was 37.4. Ischemic lesions were more conspicuous and/or extensive on diffusion-weighted imaging in all except one neonate. The presence of normal findings on both diffusion-weighted imaging and conventional magnetic resonance imaging is predictive of a normal neuromotor outcome, whereas lactate and a reduced ratio of N-acetylaspartate to total creatine in the basal ganglia, but not an apparent diffusion coefficient, are associated with an abnormal outcome at 18 months of age.