Early‐onset hypoparathyroidism and chronic keratitis revealing APECED

Early diagnosis of potentially life‐threatening autoimmune polyendocrinopathy‐candidiasis‐ectodermal dystrophy (APECED) is crucial, but is often delayed due to the clinical heterogeneity of the disorder. Even in the absence of the classic disease triad of chronic mucocutaneous candidiasis, hypoparathyroidism, and adrenocortical insufficiency, a diagnosis of APECED should be considered in children who have hypoparathyroidism and chronic keratitis, with a past medical history showing a mild and transient Candida infection.     

Determination of the renal concentration capacity following intravenous administration of dDAVP in healthy humans

The synthetic AVP analogue 1-desamino-8-d-arginine-vasopressin (dDAVP) is used for treatment of polyuric disorders. Lack of commercially available assays limits the usefulness of dDAVP as a diagnostic tool in the assessment of renal concentrating capacity. We aimed to develop a specific radioimmunoassay (RIA) for determination of plasma dDAVP (pdDAVP) in order to investigate the relationship between pdDAVP levels and urine osmolality (Uosm). Further, we aimed to determine the onset, duration, and maximum concentrating capacity following intravenous (i.v.) bolus dDAVP injection. The dDAVP assay was based on a well-established RIA for measurements of AVP. Fourteen healthy subjects (aged 15–18 years) participated. Blood and urine samples were collected prior to and after i.v. bolus of 0.03?µg/kg dDAVP. Diuresis and Uosm was measured for nine hours following dDAVP administration. PdDAVP and Uosm were analyzed.We established a specific RIA for the measurement of pdDAVP. All subjects reached maximal pdDAVP concentration (C_max) 30 minutes following infusion, and a rise in Uosm after 60 minutes. Maximal Uosm varied between subjects, with no direct correlation to the achieved pdDAVP levels. We found no significant intra-individual variation between two dDAVP infusions and the effect was reproducible in terms of C_max and maximal Uosm. We characterized the relationship between pdDAVP and Uosm after dDAVP bolus injection in healthy adolescents using our dDAVP assay. Maximal Uosm achieved correlated with the baseline Uosm levels and seemed unrelated to achieved pdDAVP levels. The urine concentrating response was maintained at least eight hours.     

Examining the Role of Repetitive Negative Thinking in Relations Between Positive and Negative Aspects of Self-compassion and Symptom Improvement During Intensive Treatment

Positive aspects of self-compassion (i.e., self-kindness and nonjudgmental acceptance of personal experiences) as well as negative aspects (i.e., high self-criticism and self-coldness) are strong predictors of anxiety, depression, worry, and quality of life. To date, however, relatively little is known about (a) how both aspects of self-compassion change during naturalistic treatment, (b) whether and how such changes relate to symptom improvement, and (c) which processes might explain the potential benefits of self-compassion. To address these gaps, the present study examined whether relations between changes in both aspects of self-compassion and treatment outcomes in a brief partial hospital setting for acute psychology could be explained by associated changes in repetitive negative thinking (RNT), an established maladaptive cognitive process involved in anxiety and depressive disorders. In a sample of 582 people receiving cognitive-behavioral (CBT) and dialectical behavior therapy over the course of 1–2 weeks, increases in positive aspects of self-compassion and decreases in negative aspects related to improvements in depression and anxiety. RNT mediated the relationship between decreases in negative aspects of self-compassion and improvements in anxiety and depression. However, a reverse model also showed that decreases in negative aspects of self-compassion could also explain relations between RNT and depressive symptom improvement only. These findings suggest that negative aspects of self-compassion and RNT may constitute important targets for treatment in acute settings. Future studies should investigate the impact of greater focus on self-compassion on RNT and symptom improvement using longitudinal experimental designs with multiple assessment points, examining causality and directionality.     

Quality of Relationships With Caregivers,Depression, and Life Satisfaction After Dysvascular Lower Extremity Amputation

Objective

To describe the relationship between caregiver-specific support and conflict, and psychosocial outcomes among individuals experiencing their first dysvascular lower extremity amputation (LEA).

Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock

Purpose

Guidelines for shock recommend mean arterial pressure (MAP) targets for vasopressor therapy of at least 65 mmHg and, until recently, suggested that patients with underlying chronic hypertension and atherosclerosis may benefit from higher targets. We conducted an individual patient-data meta-analysis of recent trials to determine if patient variables modify the effect of different MAP targets.

Methods

We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for randomized controlled trials of higher versus lower blood pressure targets for vasopressor therapy in adult patients in shock (until November 2017). After obtaining individual patient data from both eligible trials, we used a modified version of the Cochrane Collaboration’s instrument to assess the risk of bias of included trials. The primary outcome was 28-day mortality.

Results

Included trials enrolled 894 patients. Controlling for trial and site, the OR for 28-day mortality for the higher versus lower MAP targets was 1.15 (95% CI 0.87–1.52). Treatment effect varied by duration of vasopressors before randomization (interaction p = 0.017), but not by chronic hypertension, congestive heart failure or age. Risk of death increased in higher MAP groups among patients on vasopressors > 6 h before randomization (OR 3.00, 95% CI 1.33–6.74).

Conclusions

Targeting higher blood pressure targets may increase mortality in patients who have been treated with vasopressors for more than 6 h. Lower blood pressure targets were not associated with patient-important adverse events in any subgroup, including chronically hypertensive patients.