Risks of suicidality in adult patients with epilepsy

AIM: To determine the prevalence and risks of suicidality in a group of patients with epilepsy. METHODS: Included were 200 adult patients and 100 matched healthy subjects. The clinical interview using The Diagnostic and Statistical Manual of Mental Disorders (4th edition), Beck Depression Inventory (2nd edition) (BDI-II), Hamilton Anxiety Rating Scale (HAM-A), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and Eysenck Personality Questionnaire-Revised Rating Scale testings were used for diagnosis and assessment of severity of psychiatric symptoms. Blood concentrations of serotonin, catecholamines and dopamine were also measured. RESULTS: Suicidality was reported in 35% (compared to 9% for controls), of them 80%, 72.86%, 55.71% and 52.9% had depression, anxiety, obsession and aggression respectively. Patients with suicidality had higher scores of BDI-II (P = 0.0001), HAM-A (P = 0.0001), and Y-BOCS (P = 0.037) and lower scores of psychotic (P = 0.0001) and extroversion (P = 0.025) personality traits. Regardless the presence or absence of suicidality, patients with epilepsy had low serotonin (P = 0.006), noradrenaline (P = 0.019) and adrenaline (P = 0.0001) levels. With suicidality, significant correlations were identified between: (1) age and scores of BDI-II (r = 0.235, P = 0.0001) and HAM-A (r = 0.241, P = 0.046); (2) age at onset and concentrations of noradrenaline (r = -0.502, P = 0.024); (3) duration of illness and scores of BDI-II (r = 0.247, P = 0.041), Y-BOCS (r = 0.270, P = 0.025) and neurotic personality trait (r = -0.284, P = 0.018); and (4) doses of antiepileptic drugs and scores of psychotic personality traits (r = -0.495, P = 0.006 for carbamazepine; r = -0.508, P = 0.0001 for valproate). CONCLUSION: This is the first study which systematically estimated the prevalence and risks of suicidality in a homogenous group of patients with epilepsy. This study emphasizes the importance of epilepsy itself as a risk for suicidality and not its treatment.     

Oral lichenoid drug eruptions

OBJECTIVES: To identify, from amongst drugs reported as causing lichenoid drug eruptions, those affecting the oral mucous membranes and to review the clinical, histo-logical and immunological features of such oral lichenoid drug eruptions in comparison to oral lichen planus, amalgam contact lesions and lichen planus-like eruption in graft-versus-host disease (GVHD).
DATA SOURCES: Ovid® Medline data searches on CD-Rom were carried out for the years 1966–1996 to identify reports of oral lichenoid drug eruptions and their clinical, histological and immunological featureS. Articles retrieved were examined for further appropriate references in the period 1940–1996.
DATA EXTRACTION AND SYNTHESIS: Each paper was critically examined for evidence of a clinically verifiable lichenoid drug eruption affecting the oral mucous membranes and the effects of subsequent drug withdrawal. Available clinical, histological and immunological features were recorded. The papers examined were too diverse in nature to permit a structured criticism. The extracted data have been tabulated where appropriate.
CONCLUSIONS: The reports of oral lichenoid drug eruptions are considerably fewer than those of cutaneous eruptions and fewer drugs have been reported as causing oral rather than cutaneous lichenoid eruptionS. Histology and immunology cannot be used reliably to differentiate lichenoid drug eruptions from idiopathic lichen planus, amalgam contact lesions and lichen planus-like eruption in GVHD. Lichenoid drug eruptions may also show some histological characteristics of oral discoid lupus erythematosuS. An accepted protocol agreed by a number of international centres would permit the gathering of substantial information on LDE and could lead to a greater understanding of the mechanisms involved.     

Noninvasive single-beat determination of left ventricular end-systolic elastance in humans

OBJECTIVES: The goal of this study was to develop and validate a method to estimate left ventricular end-systolic elastance (E(es)) in humans from noninvasive single-beat parameters. BACKGROUND: Left ventricular end-systolic elastance is a major determinant of cardiac systolic function and ventricular-arterial interaction. However, its use in heart failure assessment and management is limited by lack of a simple means to measure it noninvasively. This study presents a new noninvasive method and validates it against invasively measured E(es). METHODS: Left ventricular end-systolic elastance was calculated by a modified single-beat method employing systolic (P(s)) and diastolic (P(d)) arm-cuff pressures, echo-Doppler stroke volume (SV), echo-derived ejection fraction (EF) and an estimated normalized ventricular elastance at arterial end-diastole (E(Nd)): E(es(sb)) = [P(d) - (E(Nd(est)) x P(s) x 0.9)[/(E(Nd(est)) x SV). The E(Nd) was estimated from a group-averaged value adjusted for individual contractile/loading effects; E(es(sb)) estimates were compared with invasively measured values in 43 patients with varying cardiovascular disorders, with additional data recorded after inotropic stimulation (n = 18, dobutamine 5 to 10 microg/kg per min). Investigators performing noninvasive analysis were blinded to the invasive results. RESULTS: Combined baseline and dobutamine-stimulated E(es) ranged 0.4 to 8.4 mm Hg/ml and was well predicted by E(es(sb)) over the full range: E(es) = 0.86 x E(es(sb)) + 0.40 (r = 0.91, SEE = 0.64, p < 0.00001, n = 72). Absolute change in E(es(sb)) before and after dobutamine also correlated well with invasive measures: E(es(sb)): DeltaE(es) = 0.86 x DeltaE(es(sb)) + 0.67 (r = 0.88, p < 0.00001). Repeated measures of E(es(sb)) over two months in a separate group of patients (n = 7) yielded a coefficient of variation of 20.3 +/- 6%. CONCLUSIONS: The E(es) can be reliably estimated from simple noninvasive measurements. This approach should broaden the clinical applicability of this useful parameter for assessing systolic function, therapeutic response and ventricular-arterial interaction.     

Continuous Measurement of Multiple Inert and Respiratory Gas Exchange in an Anaesthetic Breathing System by Continuous Indirect Calorimetry

A method was tested which permits continuous monitoring from a breathing system of the rate of uptake of multiple gas species, such as occurs in patients during inhalational anaesthesia. The method is an indirect calorimetry technique which uses fresh gas rotameters for control, regulation and measurement of the gas flows into the system, with continuous sampling of mixed exhaust gas, and frequent automated recalibration to maintain accuracy. Its accuracy was tested in 16 patients undergoing pre-cardiopulmonary bypass coronary artery surgery, breathing mixtures of oxygen/air and sevoflurane with/without nitrous oxide, by comparison with the reverse Fick method. Overall mean bias [95% confidence interval (CI)] of rate of uptake was 17.9 [7.3 to 28.5] ml min⁻¹ for oxygen, 0.04 [−0.42 to 0.50] ml min⁻¹ for sevoflurane, 10.9 [−16.1 to 37.8] for CO₂, and 8.8 [−14.8 to 32.4] ml min⁻¹ for nitrous oxide where present. The method proved to be accurate and precise, and allows continuous monitoring of exchange of multiple gases using standard gas analysis devices. Stuart-Andrews C, Peyton P, Humphries C, Robinson G, Lithgow B. Continuous measurement of multiple inert and respiratory gas exchange in an anaesthetic breathing system by continuous indirect calorimetry.     

Manipulation: investigation of a proposed mechanism

The purpose of this study was to investigate whether spinal manipulation alters the posteroanterior stiffness of the manipulated region. Thirty subjects with no history of thoracic pain or contraindication to manipulation participated. The manipulation studied was a posteroanterior thrust applied to the T_4–5 spinal level. The effect of the manipulation was compared to a control intervention of supine lying. The posteroanterior stiffness of all subjects was measured at the T₄ and T₅ levels initially, and remeasured after both the manipulation and control interventions. Change scores relating to the change in posteroanterior stiffness due to manipulation and due to the control intervention were computed. A t-test comparing the change scores between interventions revealed no significant difference. However, the posteroanterior stiffness at T₅ was found to be significantly greater than at T₄. It was concluded that in the case of asymptomatic subjects these results did not provide support for the hypothesis that posteroanterior stiffness is altered by manipulation.     

In vitro squeeze-flow phenomena at the instant of mechanical valve closure

Cavitation bubble formation associated with mechanical valve closure has been investigated in vitro, and the region of bubble formation has been correlated with large negative pressure transients. The region of cavitation bubbles forms in valve designs where leaflets interact with seat stops. It has been postulated that the fluid is squeezed between the leaflet and the seat stop and radially propelled at high velocities, resulting in further pressure reduction below the vapor pressure of fluid and initiating cavitation bubble formation. We conducted in vitro experiments to visualize and detect the presence of squeeze-flow phenomena associated with valve closure of mechanical heart valves. The closing dynamics were studied by simulating a single closing event of the leaflet with the valve mounted at the mitral position. Squeeze flow was detected at the instant of valve closure, when the valve leaflet interacts with the valve seat stop. The use of a high-speed video camera at 1000 frames per second with strobe light at 16000 pulses per second enabled the visualization of cavitation bubbles and its radial motion from the valve's seat stop due to the squeeze-flow effect. Vapor cavitation bubbles were observed to collapse within 0.5 ms after inception. In mechanical valves without seat stops in the major orifice region, bubbles of duration longer than that of the cavitation bubbles were observed. These microbubbles were present for 4 s before collapsing and are believed to be air bubbles whose presence in vivo has been detected with ultrasound imaging.     

Maintenance of morphology and function of mixed liver cell spheroids under collagen gel environment

Mixed liver cell spheroids from rats consisting of hepatocytes and nonparenchymal cells lose three-dimensional structure and function when cultured on dishes. In order to maintain the configuration and function of the spheroids, we cultured them with collagen gel in various conditions, such as on the surface of collagen gel (group 2), between two collagen gel layers (group 3), and within collagen gel (group 4). Spheroids cultured on a standard collagen-coated dish were used as controls (group 1). Culture was continued for 10 days. Phase-contrast microscopy revealed that the spheroids of group 1 lost their spheroidal configuration and became a monolayer within 24 h. Group 2 spheroids also spread out to a monolayer, but thus occurred at 24 to 48h. In group 3, spheroid configuration was sustained until day 10, though slightly flattened. In group 4, the spheroid configuration was well maintained throughout the culture period. Urea synthesis of the spheroids cultured with collagen gel was significantly higher than in group 1 between days 1 and 3. Albumin synthesis of three experimental groups was also significantly higher than that of group 1. Although three experimental groups showed no difference in urea synthesis, albumin production by spheroids in groups 3 and 4 was better maintained than in group 2, even toward the end of the culture period. It is concluded that mixed liver-cell spheroid culture within collagen gels showed better maintenance of their configuration and function.