Glaucoma and Psychotropics

Introduction

Glaucoma is a heterogeneous group of conditions which result in optic neuropathy and visual defects, majorly linked with the increase of intra-ocular pressure (IOP). It is known that psychotropic drugs have been implicated in drug induced angle-closure glaucoma, mostly through its anti-cholinergic effect.

Objectives

Systematize the drugs most and least implicated in its appearance and worsening and understand the care needed on prescribing.

Methods

A search on Pubmed database was made having in consideration the Mesh Terms Glaucoma and Psychotropic Drugs and its different classes. Specific searches were made when appropriate on different platforms.

Results

Implications on the appearance and worsening of glaucoma are clear for tricyclic antidepressants. The evidence is not clear for SSRIs, SNRIs and mirtazapine, but they might be related with increased IOP. Other classes of antidepressants seem to be of lower risk. Antipsychotics do not seem to be greatly associated with angle closure, although there are some case reports. There are descriptions of the potencial use of haloperidol, anti-convulsive mood stabilizers, with exception of topiramate, melatonin and anti-dementia drugs on the treatment of this condition. In practice, benzodiazepines do not seem to precipate angle-closure. Methamphetamines are contraindicated. Eletroconvulsive therapy its an option.

Conclusions

Although not prevalent, angle-closure glaucoma can have serious implications and culminate in irreversible blindness. In patients with known risk-factors its important to have it on consideration at the time of the prescription and warn on seeking immediate help if having acute ocular pain, redness and/ or cloudy vision.

Disclosure

No significant relationships.

Delirium in COVID-19: psychopharmacology considerations

Introduction

Delirium is characterized by fluctuating disturbance of consciousness, inattention, reduced awareness, hallucinations or delusions, occurring in 20% of hospital admissions. Central nervous system symptoms are the main form of neurologic injury in patients with COVID-19 and a significant portion of these patients presents with delirium. COVID-19 infection’s course and symptoms, as well as patient comorbidities can facilitate its onset, which is exacerbated by the frequent need for higher doses of sedation to suppress severe cough.

Objectives

To summarize the most recent practices for management of delirium in COVID-19 infected patients, with emphasis on the psychopharmacology approach.

Methods

Selective literature review via PubMed search, using the terms “delirium, neurological disorders, psychopharmacology and COVID-19”.

Results

COVID-19 associated delirium can be presented in its hyperactive type with exuberant agitation, but also with additional clinical features such as rigidity, akinetic mutism, abulia and alogia. Psychopharmacological approaches may be needed for patients with agitation when there’s intractable stress or risk to self or others. In this group of patients, melatonin, alfa-2 agonists and low potency antipsychotics have been used as first line treatment. Trazodone, valproate, dopamine agonists, amantadine can be used. Other approaches such as correction of vitamin deficiencies and remdesivir can also play a role.

Conclusions

Delirium remains frequently unrecognized. In the pandemic context of COVID-19 it is important to consider this infection as a cause of delirium and mind the misdiagnosis as a psychiatric condition. One should look for atypical features and be more thoughtful about the psychopharmacological approach.

Supraventricular ectopic activity as a predictor of atrial fibrillation – what we didn't see 10 years ago

Background

Cardioembolism induced by atrial fibrillation (AF) is responsible for up to 33% of all ischemic strokes. 24-hour Holter monitoring in stroke and transient ischemic attack (TIA) patients is used as a routine investigation to search for occult paroxysmal atrial fibrillation (PAF), which may have crucial prognostic impact. Excessive supraventricular ectopic activity (ESVEA) is also a stroke risk factor, probably related to the risk of developing AF.

Purpose

To observe the incidence of AF at a long-term follow-up and to evaluate the clinical, electrocardiographic and echocardiographic predictors of new onset AF in stroke patients.

Methods

Patients in sinus rhythm who performed Holter between October 2009 and October 2011 in the setting of post stroke or TIA were included; patients with previous AF were excluded. These patients were followed for 8 to 10 years. Clinical, electrocardiographic and echocardiographic data were collected. ESVEA was defined by ≥500 premature atrial contractions per 24 hours or any sustained supraventricular tachycardia episode.

Results

104 patients were included, 54% were male, with a mean age of 63.8±14.7 years at the time of the event. In relation to cardiovascular risk factors, 59% had hypertension, 47% dyslipidemia, 14% diabetes, 44% were smokers or previous smokers; 67% of patients were high consumers of alcohol. 79.8% had a stroke and 21.2% a TIA. 24-hour Holter monitoring revealed ESVEA in 13.5% of patients and PAF in 1.9%. All patients with PAF had a previous stroke and were older than 55.

At a follow-up of 8–10 years, new onset AF was detected in 11.5%; these patients had similar mortality comparing to those in sustained sinus rhythm (21.2% vs 16.7%, p=0.724). Alcohol intake, an established risk factor for development of AF, was associated with a non-significant increase of AF (17.3% vs 11.5%) while the presence of cardiovascular risk factors was not associated with AF development. We found a statistically significant difference between patients with and without ESVEA concerning to new onset of AF (35.7% vs 8.0%, p=0.010). ESVEA seems to be related with a higher mortality at a long follow-up, although this difference wasn't statistically significant (35.7% vs 18.2%, p=0.132). Concerning to echocardiographic parameters, patients whit left atrium enlargement showed a higher incidence of AF at follow-up (14.7% vs 7.9%), and the presence of mitral regurgitation were not related with new onset of AF. Patients' age was also not related with new onset of AF during follow-up.

Conclusion

Atrial fibrillation is considered the main cause of stroke. Our study showed that ESVEA is a strong predictor of new onset AF and highlights that Holter monitoring could be an important tool not only to diagnose AF but also to identify patients in risk of develop AF. Diagnostic of new AF during long-term follow up didn't correlate with higher mortality.

Funding Acknowledgement

Type of funding source: None

Stacking broiler litter to reduce natural hormones

Estrone, 17β-estradiol, and testosterone are naturally occurring hormones excreted in broiler litter. With some potential for environmental concern from the hormones, understanding management practices effect on hormone concentrations is beneficial for the poultry industry. As the amount of hormones potentially introduced into the environment is directly related to the concentration at the time of land application, the purpose of this study was to investigate hormone dynamics in stacked broiler litter during the storage period before removal from the farm and/or land application. Stack temperatures and hormones concentrations were monitored at 15, 45, 75 cm, and 105 cm (measured from the stack bottom) in 6 different on-farm stack houses over 4 or 8 wk. Significant differences in temperature were determined by height and by stack. Stack temperatures during the first 4 wk ranged from 41.5°C to 54.5°C, and all stacks reached maximum temperature by 7 D. Highest temperatures were observed at the 45-cm or 75-cm height. Average stack temperatures correlated with the ambient temperature. Hormone concentration did not vary with height within each house. In 5 of the 6 stack houses, the concentrations of 17β-estradiol and/or testosterone significantly decreased after stacking for 4 or 8 wk (35 to 64%) with only one house showing a significant decrease in estrone concentration (72% in 4 wk). The percent change of estrone and 17β-estradiol mineralization during the first 4 wk was negatively correlated with the 7-D temperature of the pile (r² = 0.80), indicating that the high temperatures observed during stacking may inhibit estrogen mineralization. In this study, hormone degradation decreased with high temperatures. Therefore, stack management favoring at least a period of low temperatures may help promote mineralization of these hormones and reduce any potential for introduction into the surrounding environment.

Long-term broiler litter amendments can alter the soil's capacity to sorb monensin

Monensin is a common antiparasitic drug given to poultry that contaminates poultry manure and bedding material (broiler litter). As broiler litter is commonly applied to agricultural fields as fertilizer, monensin could be released beyond the farm if it is not retained or degraded in the soil. This study aimed to assess the impact of long-term surface application of broiler litter (i.e., 17 years) on the capacity of pasture soil to sorb monensin. The soils were exposed to a range of monensin concentrations (0.18 to 1.81 μmol L^-1), solution pH (pH 4-9), and temperatures (15, 25, and 35 °C) and monensin was measured as loss from solution (i.e., sorption). Soils receiving long-term litter applications were hypothesized to retain more monensin than unamended soils because they have higher organic matter concentrations. However, soils from broiler litter-amended fields sorbed 46% less monensin than soils from unamended fields, likely because broiler litter also increased soil pH. The sorption of monensin to soil was strongly influenced by pH, with an order of magnitude greater sorption at pH 4 than at pH 9. Both soils had similar capacity to sorb monensin under similar solution pH, despite differences in organic carbon content (with the broiler litter-amended having 25% greater relative to the unamended soil). Temperature did not significantly impact monensin sorption for either soil. Our findings suggest increasing soil pH, for instance through liming, could enhance mobility of monensin.

Stacking Time and Aluminum Sulfate Effects on Polyether Ionophores in Broiler Litter

The use of ionophores as antiparasitic drugs plays an important role in US poultry production, especially in the broiler () industry. However, administered ionophores can pass through the bird's digestive system and appear in broiler litter, which, when applied to agricultural fields, can present an environmental hazard. Stacking (storing or stockpiling) broiler litter for some time might decrease the litter ionophore concentrations before land application. Because ionophores undergo abiotic hydrolysis at low pH, decreasing litter pH with acidic aluminum sulfate (alum) might also decrease ionophore concentrations. We assessed the change in ionophore concentrations in broiler litter in response to the length of time broiler litter was stored (stacking time) and alum addition. We spiked broiler litter with monensin and salinomycin, placed alum-amended litter (∼pH 4-5) and unamended litter (∼pH 8-9) into 1.8-m bins, and repeatedly sampled each bin for 112 d. Our findings showed that stacking broiler litter alone did not have an impact on monensin concentration, but it did slowly reduce salinomycin concentration by 55%. Adding alum to broiler litter reduced monensin concentration by approximately 20% relative to unamended litter, but it did not change salinomycin concentration. These results call for continued search for alternative strategies that could potentially reduce the concentration of ionophores in broiler litter before their application to agricultural soils.

Alum and Rainfall Effects on Ionophores in Runoff from Surface-Applied Broiler Litter

Polyether ionophores, monensin, and salinomycin are commonly used as antiparasitic drugs in broiler production and may be present in broiler litter (bird excreta plus bedding material). Long-term application of broiler litter to pastures may lead to ionophore contamination of surface waters. Because polyether ionophores break down at low pH, we hypothesized that decreasing litter pH with an acidic material such as aluminum sulfate (alum) would reduce ionophore losses to runoff (i.e., monensin and salinomycin concentrations, loads, or amounts lost). We quantified ionophore loss to runoff in response to (i) addition of alum to broiler litter and (ii) length of time between litter application and the first simulated rainfall event. The factorial experiment consisted of unamended (∼pH 9) vs. alum-amended litters (∼pH 6), each combined with simulated rainfall at 0, 2, or 4 wk after litter application. Runoff from alum-amended broiler litter had 33% lower monensin concentration ( < 0.01), 57% lower monensin load ( < 0.01), 48% lower salinomycin concentration ( < 0.01), and 66% lower salinomycin load ( < 0.01) than runoff from unamended broiler litter when averaged across all events of rainfall. Ionophore losses to runoff were also less when rainfall was delayed for 2 or 4 wk after litter application relative to applying rainfall immediately after litter application. While the weather is difficult to predict, our data suggest that ionophore losses in runoff can be reduced if broiler litter applications are made to maximize dry time after application.

Management of idiopathic gingival fibromatosis: report of a case and literature review

Gingival hyperplasia is a rare condition and is of importance for cosmetic and mechanical reasons. Idiopathic gingival fibromatosis, a benign, slow-growing proliferation of the gingival tissues, is genetically heterogeneous. The enlargement is most intense during the eruption of the primary and permanent teeth, and minimal or nondetectable growth is observed in adults. The genetic aspect, clinical feature, histopathology, immunohistochemistry, and treatment aspects are reviewed. The purpose of this paper was to report a case of idiopathic gingival fibromatosis in a 13-year-old female who had a negative family history for a similar type of gingival enlargement. The diagnosis was established through history, clinical examination, and histopathology using both hematoxylin and eosin and Van Giesen stain (a special stain for collagen). Surgical treatment, which included both gingivectomy and gingivoplasty, was carried out. The case showed remarkable esthetic and functional improvement. The patient returned after a year and showed no recurrence.