[Iron deficiency: A diagnostic and therapeutic perspective in psychiatry]

BACKGROUND

Iron plays an essential role in balancing the various metabolism in the body. It is also involved in the synthesis of several neurotransmitters. Nutritional iron deficiency is one of the most widespread worldwide; it poses a great health challenge due to the consequences it entails.

OBJECTIVES

The aim of this research study is to explore the percentage of psychiatric patients who have a deficiency in iron. In addition, the study investigates the efficacy of iron administered by oral treatment on psychiatric symptomatology among iron deficient patients. The research study utilized the martial biological results, which involved the observation of the level of iron deficiency among the outpatients of a local psychiatrist and assessor from the period of January 2012 until December 2013.

METHODS

Out of 412 patients, 295 were women and 117 men. The age of the participants ranged from 16 to 89years, with an average age of 45years. The only exclusion criterion was a patient's refusal or inability to take the prescribed iron assessment test. We considered a transferrin saturation coefficient (TSC)<30% and/or a serum ferritin level≤50ng/mL to be "indicative" of obvious iron deficiency, and a ferritin level between 51 and 100ng/mL to be "suggestive" of iron deficiency. A plasma ferritin assay was performed at least once on all of the participants prior to any proposed iron treatment. A calculation of the TSC in 138 patients was requested due to suspected iron deficiency despite a blood ferritin level of>100ng/ml. A single method was utilized in the various laboratories to analyse the blood samples to determine whether there was a deficiency in iron. Only those patients with blood ferritin levels ≤100ng/mL and/or a TSC of<30% (335 patients) were subsequently given exclusively an oral iron treatment prescribed on its own or as a supplement or simultaneously with psychotropic treatment. The daily administered dose of elemental iron varied between 50 and 200mg a day.

RESULTS

About half of the women - 145 (35.19% of the subjects) - and 15 men (3.64% of the subjects) certainly had a deficiency in iron (blood ferritin level≤50ng/mL). Ninety women and 24 men (27.6% of the subjects) had blood ferritin levels between 51 and 100ng/mL indicating iron deficiency, and 28 women and 33 men (14.8% of the subjects) had a TSC of<30% despite a blood ferritin level of>100ng/mL. Overall, 335 patients (81.3% of the subjects) showed an iron deficiency based on the criteria we set. In the remaining 77 patients (18.7% of the subjects), all of them had blood ferritin levels>100ng/mL and some had TSC≤30%, while the remaining patients' TSC was unknown because it was not measured. The results indicated that there is an iron deficiency in 198 out of 240 patients suffering mostly from mood and behavioural disorders, in 101 out of 126 patients suffering mostly from anxiety disorders, in 18 out of 27 patients suffering mostly from sleep disorders, in 14 out of 15 patients suffering mostly from delusions of persecution, and in the 4 patients suffering mostly from burn out. There was evidence of regression/remission of psychiatric symptoms in 193 responsive patients whereas the remaining 142 patients were considered non-responsive. In the responsive patient category, 37 participants were treated with just iron, 52 received iron supplemented to the initial psychotropic treatment which was not fully effective, and 104 patients were treated with iron and prescribed psychotropic drugs simultaneously. The iron treatment seems to bring about a reduction - particularly through its mono-aminergic neurotransmitter synthesis-promoting action - in hyperemotivity, anxiety, irritability, aggressiveness, sadness, anhedonia, apathy, asthenia, sleep disorders, dysautonomia symptoms, eating disorders, restless-leg syndrome, cognitive performance and the likelihood of resorting to psychiatric admission. A daily elemental iron dose intake between 50 and 200mg/day by deficient patients appears to likely enhance the effects of the psychotropic drugs and even to act as an actual antidepressant. Many patients who received a prescription for iron and antidepressants showed few side effects related to antidepressants and a small number required psychiatric hospitalization. Patients considered unresponsive to iron therapy were those who left the study, were not assessed because the study's timeframe ended, still had an iron deficiency because they did not continuously take the medication, or suffered from somatic diseases which explains their resistance to treat the low iron level (nutritional imbalance, digestive or urinary or gynecological or iatrogenic diseases, sleep apnea).

CONCLUSION

Our clinical observation of two years in a local psychiatrist's clinic revealed that over 80% of patients had iron deficiency. Although the low iron level cannot explain all physical and psychiatric symptoms in patients, it is useful to note that more than half of the iron deficient patients responded favorably after an oral treatment of iron. This result leads to further investigation of the level of iron in psychiatric patients and to reconsider the iron range placed by the laboratories. In addition, it is crucial not to eliminate the possibility of iron deficiency in psychiatric patients. Further research studies are needed to set more specific and detailed criteria to determine the range of iron deficiency in order to support the findings of this study and optimize the care given to patients suffering from various disorders and psychiatric syndromes.

The argon beam coagulator: a more effective and expeditious way to address presacral bleeding

Presacral bleeding is a dreaded complication of pelvic surgery. Rapid and effective control of such bleeding is important to avoid potentially life-threatening outcomes. Various methods for controlling presacral bleeding, all with only limited success, have been described in the literature. We report the alternative technique of using the argon beam coagulator (ABC) to control presacral bleeding. We demonstrate its efficacious use in both open surgery and a laparoscopic case. Our approach involved applying an argon beam at bone setting directly to the bleeders and using a "point and shoot" technique. We found that ABC is a simpler, equally effective and expeditious way of addressing presacral bleeding. To the best of our knowledge, there has been only one previously reported case in the literature of the use of ABC to control presacral bleeding.

Small-cell carcinoma of the rectum: report of two cases

Small-cell carcinoma of the rectum is an infrequent pathologic finding, and its precise incidence is unknown. Its incidence is less than 0.2 percent among all colorectal cancers. This tumor manifests highly aggressive behavior. The treatment of choice is combination chemotherapy similar to that used for small-cell carcinoma of the lung, but in small localized tumors surgery plus chemotherapy is an alternative. We present two cases of small-cell carcinoma of the lower rectum and a review of the literature.

Recreational-outdoor burns: the impact and severity--a retrospective review of 107 patients

INTRODUCTION

Campfires, bonfires and barbecues play a prominent role in outdoor activities and serve a variety of decorative and functional purposes. Given all of it's various forms, uses and benefits, the outdoor fire can turn dangerous in a matter of seconds: a stumble or fall (the child running that trips) leads to direct contact with the flames and subsequent burn injury. With it's everyday occurrence, we were surprised to find a paucity of information regarding this type of burn in the literature, including the NBIE analysis.

METHODS

A retrospective review of 107 patients admitted to the Maricopa Medical Bum Center, from 1987 to 1996, was conducted. Each chart was analyzed for the patient demographics, mechanism of injury, percent total body surface area burned, operative versus non-operative treatment and overall outcome.

RESULTS

An average burn injury involved 5.7% TBSA, with a wide range from 1 to 47%. The majority of our population involved either small children or intoxicated adults and a total of 50 patients required 92 operations. Severe morbidity, including 4 amputations and 2 mortalities, were seen. The average hospital stay was 14.3 days, ranging from 1 to 52 days.

CONCLUSIONS

Recreational outdoor burns were extremely common injuries leading to loss of functional employment and prolonged physical therapy requirements. Small children and intoxicated adults comprised the majority of our study population. The impact and severity of such outdoor fires could be greatly affected by appropriate attention to prevention.

Using delta/DRG diagrams and decision tree analysis to select a cost-effective surgery for cholecystitis

BACKGROUND AND OBJECTIVES

Many studies have attempted cost analysis of laparoscopic cholecystectomy as compared to open cholecystectomy. However, these analyses have included costs, charges, expenses, etc., and at times they have been used interchangeably. This paper demonstrates how DRG diagrams containing charges and length-of-stay, preoperative prediction of conversion rates, decision-tree construction and sensitivity analysis can be used to select the most cost-efficient operation for a given patient with cholecystitis.

METHODS

A Delta DRG analysis for complicated cholecystectomy (DRG 195) showed the hospital to be an extreme outlier in both charges and length of stay. Record review indicated that 55% of the cases were converted laparoscopic cholecystectomies and the remainder were aged or younger patients with advanced disease. Chart and literature review determined the causes and the probability of conversion. Data were then placed into decision-tree and sensitivity analyses. The most cost-effective operation for a given probability of conversion was demonstrated.

RESULTS

Three preoperative findings and combinations of each predicted conversion rates and analysis showed that the charge of laparoscopic cholecystectomy must be held below the range of $5,361-$13,084 to make routine laparoscopic cholecystectomy cost-effective.

CONCLUSIONS

This method demonstrated that using Delta/DRG, decision-tree and sensitivity analysis offers physicians, hospitals and other health-care providers a method of evaluating the treatment of DRG categories to determine the most cost-effective management.

[Apheresis tolerance and acceptability in the child weighing 30 kg or less, with the exception of infants]

Over the ten past years, we performed 336 apheresis among 51 children who were 19 months to 15 years old (10 to 30 kg body weight). 3 types of apheresis were carried out. 14 red blood cell exchange, 293 plasma exchanges and 29 peripheral blood stem cell collections (CSP). 5 different types of continuous or discontinuous flow machines have been used. Technical adaptations depending on patient blood volume, hematocrit, type of machine used and apheresis performed permitted us to obtain a very good tolerance and acceptability. According us, the apheresis should be used each time this treatment is needed in the child, because of the very low frequency of side effects.

Immunization by bovine thrombin used with fibrin glue during cardiovascular operations. Development of thrombin and factor V inhibitors

Brief case histories of three patients aged 58, 38, and 44 years are reported. All underwent cardiovascular operations. Subsequently hemostasis test abnormalities developed between the seventh and eighth postoperative days after exposure to bovine thrombin used with fibrin glue. These were characterized by an increased activated partial thromboplastin time (64 to 147 seconds), prothrombin time (19 to 24 seconds), bovine thrombin time (> 120 seconds) and a markedly reduced factor V level (< 10% in two patients and 16% in the third patient). A patient plasma dilution of 1 in 200 with a normal plasma pool was necessary to correct bovine thrombin time. No fast-acting or progressive inhibitor against factor V could be detected by coagulation tests, and fresh frozen plasma perfusion had no effect. Plasmapheresis was performed preventatively to avoid bleeding, and factor V levels stabilized at around 50% after two to four exchanges. Immunologic studies showed that the inhibitors were directed not only against bovine factors but also against human ones. Therefore factor V decrease could have been the result of rapid clearance from the circulation of complexes formed with a nonneutralizing inhibitor that is not detected by clotting tests. These antibodies were purified by standard methods and immunoaffinity. Fast immunization could be explained by a prior sensitization to bovine thrombin exposure during previous operations. It is suggested that bovine thrombin used with fibrin glue contains small amounts of factor V and may be responsible for these abnormalities. This is in agreement with previous literature reports. However, these described neutralizing factor V inhibitors, which were easily detected.

Recurrent nephrotic syndrome after transplantation: early treatment with plasmaphaeresis and cyclophosphamide

Steroid-resistant nephrotic syndrome (NS) with focal glomerulosclerosis (FGS) and its recurrence after transplantation are mainly seen in children. The recurrence rate approximates 30% and the graft loss is about half this. Several therapeutic regimens have been proposed, giving conflicting results. In an attempt to remove a putative circulating factor and inhibit its production by lymphocytes, three patients with biopsy-proven FGS in the native kidney were included in a prospective uncontrolled trial using early plasmaphaeresis followed by substitutive immunoglobulins in association with methylprednisolone pulses and cyclophosphamide instead of azathioprine over a 2-month period. The patients were girls, aged 6.5, 13.3 and 15.8 years, who received a cadaveric transplant; concomitant immunosuppression included prednisone and cyclosporine A. All three patients exhibited early recurrence of the NS and were treated 5-10 days after the onset of proteinuria. Rapid and sustained remission was achieved in all patients within 12-24 days on therapy. One patient experienced a late acute but steroid-sensitive rejection episode; another suffered from septic ankle arthritis as a complication of reinforced immunosuppression. The latter girl had a second late recurrence of proteinuria that was controlled within 7 weeks. With a 18- to 27-month follow-up, all three patients have normal renal function, normal blood pressure and no proteinuria. We conclude that intensive therapy using plasmaphaeresis, steroid pulses and cyclophosphamide over a 2-month period can induce complete remission in children with early recurrence of NS after transplantation.

Plasma transport of 99mTc-p-butyl-IDA

Plasma transport of 99mTc-p-butyl-IDA was measured by four in vitro methods: trichloroacetic acid precipitation, electrophoresis, HPLC, and Scatchard binding isotherm. The data are in accord with protein transport, the main carrier being albumin with two categories of sites. This work suggests that after IV injection of 99mTc-p-butyl-IDA in humans plasma protein binding is one of the limiting factors for the hepatic deposition of the radiopharmaceutical.