Three clinical indicators of borderline personality disorder in anorexia nervosa: A pilot study

OBJECTIVES

Co-occurrence of Anorexia Nervosa (AN) and borderline personality disorder (BPD) is frequent (8%-40%) and associated with specificities that impact the treatment process. Lifetime history of suicide attempt (HAS), substance use disorder (SUD) and the binge-purging subtype (B-P) might be good markers of such comorbidity. We made the hypothesis that in patients with AN, the presence of HAS, SUD and B-P have sufficient predictive power to efficiently detect an associated BPD comorbidity.

METHODS

After a case report analysis on a pilot sample of 119 patients with AN, we performed a cross-sectional analysis on a confirmatory sample of 84 patients with AN in a single center specialized in eating disorders systematically assessing HAS, SUD, B-P and BPD using the Mini International Neuropsychiatric Interview for DSM-5 and the Diagnostic Interview for Borderline (DIB-R).

RESULTS

B-P had a 100% negative predictive value, and the combination of SUD plus HAS had a 100% positive predictive value. On a quantitative level, B-P, HAS and SUD were independent explanatory factors of the DIB-R total score.

CONCLUSIONS

The main limitations were the low number of patients, the single center analyses, the potential overlapping of assessments and the fact that data were exclusively declarative. In this study, every patient with B-P, SUD and HAS had been diagnosed with BPD.

Early effects predict trajectories of response to esketamine in treatment-resistant depression

BACKGROUND

The efficacy of esketamine in treatment-resistant depression (TRD) has been confirmed. However, its administration is expensive and restrictive, with limited knowledge on how long the treatment should be continued. Predicting the treatment outcome would benefit patients and alleviate the global treatment cost. We aimed to define distinct trajectories of treatment response and assess their predictability.

METHODS

In this longitudinal study, two independent samples of patients with unipolar or bipolar TRD were treated with esketamine in real-world settings. Depression severity was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS) before each esketamine administration. Latent class analyses were used to define trajectories of response.

RESULTS

In the original sample (N = 50), we identified two classes whose trajectories depicted response and non-response, respectively. The model was validated in the confirmatory sample (N = 55). Class membership was influenced by a few baseline characteristics such as concomitant benzodiazepine medication, number of depressive episodes or polarity. On the other hand, after only two esketamine administrations, the MADRS score predicted the 90-day trajectory of response with an accuracy of 80 %.

LIMITATIONS

This observational study is not placebo-controlled. Therefore, its results and their generalizability need to be confirmed in experimental settings.

CONCLUSIONS

After the first administrations of esketamine, the MADRS score has a good capacity to predict the most plausible trajectory of response. While thresholds and their predictive values need to be confirmed, this finding suggests that clinicians could base on MADRS scores their decision to discontinue treatment because of poor remaining chances of treatment response.

Enzyme replacement therapy in the mouse model of Pompe disease

Deficiency of acid alpha-glucosidase (GAA) results in widespread cellular deposition of lysosomal glycogen manifesting as myopathy and cardiomyopathy. When GAA-/- mice were treated with rhGAA (20 mg/kg/week for up to 5 months), skeletal muscle cells took up little enzyme compared to liver and heart. Glycogen reduction was less than 50%, and some fibers showed little or no glycogen clearance. A dose of 100 mg/kg/week resulted in approximately 75% glycogen clearance in skeletal muscle. The enzyme reduced cardiac glycogen to undetectable levels at either dose. Skeletal muscle fibers with residual glycogen showed immunoreactivity for LAMP-1/LAMP-2, indicating that undigested glycogen remained in proliferating lysosomes. Glycogen clearance was more pronounced in type 1 fibers, and histochemical analysis suggested an increased mannose-6-phosphate receptor immunoreactivity in these fibers. Differential transport of enzyme into lysosomes may explain the strikingly uneven pattern of glycogen removal. Autophagic vacuoles, a feature of both the mouse model and the human disease, persisted despite glycogen clearance. In some groups a modest glycogen reduction was accompanied by improved muscle strength. These studies suggest that enzyme replacement therapy, although at much higher doses than in other lysosomal diseases, has the potential to reverse cardiac pathology and to reduce the glycogen level in skeletal muscle.

Surprises of genetic engineering: a possible model of polyglucosan body disease

BACKGROUND

The authors previously reported the generation of a knockout mouse model of Pompe disease caused by the inherited deficiency of lysosomal acid alpha-glucosidase (GAA). The disorder in the knockout mice (GAA-/-) resembles the human disease closely, except that the clinical symptoms develop late relative to the lifespan of the animals. In an attempt to accelerate the course of the disease in the knockouts, the authors increased the level of cytoplasmic glycogen by overexpressing glycogen synthase (GSase) or GlutI glucose transporter.

METHODS

GAA-/- mice were crossed to transgenic mice overexpressing GSase or GlutI in skeletal muscle.

RESULTS

Both transgenics on a GAA knockout background (GS/GAA-/- and GlutI/GAA-/-) developed a severe muscle wasting disorder with an early age at onset. This finding, however, is not the major focus of the study. Unexpectedly, the mice bearing the GSase transgene, but not those bearing the GlutI transgene, accumulated structurally abnormal polysaccharide (polyglucosan) similar to that observed in patients with Lafora disease, glycogenosis type IV, and glycogenosis type VII. Ultrastructurally, the periodic acid-Schiff (PAS)-positive polysaccharide inclusions were composed of short, amorphous, irregular branching filaments indistinguishable from classic polyglucosan bodies. The authors show here that increased level of GSase in the presence of normal glycogen branching enzyme (GBE) activity leads to polyglucosan accumulation. The authors have further shown that inactivation of lysosomal acid alpha-glucosidase in the knockout mice does not contribute to the process of polyglucosan formation.

CONCLUSIONS

An imbalance between GSase and GBE activities is proposed as the mechanism involved in the production of polyglucosan bodies. The authors may have inadvertently created a "muscle polyglucosan disease" by simulating the mechanism for polyglucosan formation.

Lipid profile in congenital adrenal hyperplasia

Glucocorticoids have been reported to exert a marked effect on lipoprotein metabolism. Several studies have shown a potential risk of hyperlipidemia in patients under long-term glucocorticoid therapy. Current management of patients with congenital adrenal hyperplasia (CAH) includes the use of glucocorticoids to attenuate the increased production of undesirable adrenal hormones. A case-control study was designed to compare the serum lipid profiles of 14 patients with CAH under glucocorticoid therapy and 14 normal controls and to determine the characteristics of the profiles. A total of 9 patients (64.3%) had serum total cholesterol (TC) greater than 4.4 mmol/L (170 mg/dL), compared with 6 individuals in the control group (42.3%). Nine patients with CAH (64.3%) had serum triglycerides (TGs) more than 1.0 mmol/L (90 mg/dL), compared with only 2 in the control group (14.3%). Similarly, the mean serum TG was higher in the CAH group versus the controls, 1.33 mmol/L (118 mg/dL) versus 0.75 mmol/L (67 mg/dL), respectively. Serum low-density lipoprotein, (LDL-C) and high-density, lipoprotein (HDL-C) cholesterol were determined in 13 children with CAH and in the 14 controls. Nine CAH patients (69.2%) and 8 controls (57%) had LDL-C greater than 2.8 mmol/L (<110 mg/dL). For HDL-C, 2 children with CAH (15.4%) and 4 controls (28.6%) had levels less than 0.9 mmol/L (35 mg/dL). There were no significant differences for the cholesterol index, 0.24 for the controls and 0.22 for the CAH group. In the CAH group, the mean serum TG level and the percentage of individuals with TGs greater than 1.0 mmol/L were statistically significant compared with the controls. The mean serum TC and LDL-C, as well as the percentage of subjects with levels over the cutoff point, although slightly higher in the CAH group, were of no statistical significance. The results of this pilot study suggest that long-term glucocorticoid therapy in patients with CAH may induce abnormalities in the serum lipid profile characterized mainly by an increment in serum TGs.

Recent advances in the diagnosis and treatment of precocious puberty

In the last two decades, the diagnosis and treatment of precocious puberty has undergone important changes. The use of supersensitive assays to determine gonadotropins and gonadal hormones has increased the sensitivity and decreased the number of blood samples required to assess the diagnosis. The introduction of gonadotropin-releasing hormone (GnRH) agonists produced a revolution in the diagnosis and treatment of this disorder. Recently, the use of long acting GnRH agonists improved the adherence of patients to medical treatment and decreased the need for uncomfortable repeated doses. The medications in the treatment of the GnRH independent causes of precocious puberty, and the important revelations in the pathophysiology of these disorders, have advanced our knowledge and management of the affected children.

Serum inhibin B levels and the response to gonadotropin stimulation test in pubertal boys with varicocele

PURPOSE

The impact of varicoceles on gonadal function in adolescents has been evaluated using several parameters, including size of testes, hormonal levels and provocative endocrine testing. Inhibin B has been demonstrated to be decreased in men with testicular damage from conditions other than varicocele. We determine whether inhibin B levels are low in adolescent boys with varicocele, and if there is a relationship between inhibin B and an exaggerated response to gonadotropin-releasing hormone (Gn-RH) stimulation testing, testicular hypertrophy and/or varicocele bilaterality.

MATERIALS AND METHODS

We studied 9 boys at Tanner stages III to V of pubertal development who had either left or bilateral varicoceles. Basal inhibin B, follicle-stimulating hormone, luteinizing hormone and testosterone were measured. Each patient underwent Gn-RH stimulation testing.

RESULTS

All patients had essentially normal inhibin B levels for Tanner stage. Of the 9 boys 4 had an exaggerated response to Gn-RH stimulating testing. Inhibin B levels did not vary significantly either with the presence of bilateral or unilateral varicoceles or asymmetric testis.

CONCLUSIONS

The lack of correlation between inhibin B levels and the aforementioned parameters failed to suggest that inhibin B has a significant role in the clinical assessment of testicular function in adolescents with varicocele. Further studies of larger populations may further elucidate the value of inhibin B levels and varicoceles.

Comprehensive assessment of the components of energy expenditure in infants using a new infant respiratory chamber

BACKGROUND

Current methods for energy expenditure (EE) measurements in term infants do not include simultaneous measurements of basal and sleeping metabolic rates (BMR and SMR) or a measure of physical activity (PA). Furthermore, prediction equations for calculating EE are not appropriate for use in infants with metabolic disorders.

OBJECTIVE

To develop and utilize a new infant respiratory chamber for simultaneous measurements of EE (kJ/d), preprandial BMR (kJ/d), SMR (kJ/d) and an index of PA (oscillations/min/kg body weight) in infants with a variety of metabolic disorders, for up to four hours in a hospital setting, while allowing parental interaction in a comfortable environment.

METHODS

We obtained simultaneous measurements of EE, BMR, SMR and PA in 21 infants (66+/-73 days of age, 4.5+/-1.7 kg body weight, 55+/-8 cm in length and 16+/-7% body fat) using our new infant respiratory chamber. Six of these infants were healthy, seven had thyroid dysfunction, five were HIV-exposed, one had AIDS, one had intrauterine and postnatal growth retardation and one was a hypothermic preterm infant. Energy expenditure, BMR and SMR were extrapolated for 24 hours. Body composition was estimated by skin-fold thickness, using age-appropriate formulae. Basal metabolic rate obtained with the infant respiratory chamber was compared to BMR that was calculated using the appropriate World Health Organization (WHO) equations.

RESULTS

In all infants both extrapolated 24-hour EE and BMR correlated with fat-free mass (r = 0.89, p<0.01 and r = 0.88, p<0.01 respectively). Twenty-four hour EE also correlated with PA (r = 0.52, p<0.05). The HIV-exposed infants had higher BMR (p<0.05) than that calculated by the appropriate WHO equation. We found that the caloric requirements for the infant with growth retardation were underestimated based on the infant's weight and age.

CONCLUSIONS

The infant respiratory chamber can measure all of the main components of EE. Some of the results obtained differed significantly from those obtained by the WHO equations; therefore, the new infant respiratory chamber is necessary for estimating EE in infants with metabolic and growth disorders.

IL-10 production in common variable immunodeficiency

Common variable immunodeficiency, (CVI) is a heterogeneous primary immunodeficiency disease in which there are T and B cell defects. Since IL-10 in conjunction with anti-CD40 promotes secretion of IgG, IgA, and IgM by CVI B cells, these studies were performed to investigate IL-10 production in CVI. Mitogen or anti-CD3 stimulated CVI peripheral blood mononuclear cells, or isolated T cells produced an insignificant amount of IL-10 over background levels. CVI monocyte IL-10 production was substantial and greater than that of normal controls. Anti-IL-10-neutralizing antibody strongly enhanced CVI T cell proliferative responses to PHA, but only to an insignificant extent, soluble antigens. IL-2 plus anti-IL-10 enhanced CVI proliferative responses to antigens significantly more over baseline than for cells of similarly tested normal controls. These data suggest that CVI T cell secretion of IL-10 is deficient, but that monocyte-derived IL-10, plus a relative lack of IL-2 production, could contribute to the defects of cell proliferation in this disorder.

Prednisone dose limitation of growth hormone treatment of steroid-induced growth failure

Seven children with prednisone-induced growth failure were treated with recombinant growth hormone to improve linear growth. Six of seven patients had an increase in linear growth during therapy with recombinant growth hormone. The response to recombinant growth hormone was found to be related to the prednisone dose. When the prednisone dose was greater than 0.35 mg/kg per day, recombinant growth hormone did not increase the linear growth rate. At lower doses the response was inversely related to the amount of prednisone taken.

An updated protocol for abortion surveillance with ultrasound and immediate pathology

OBJECTIVE

To modify and improve a protocol for surveillance of patients presenting for routine elective abortion services.

METHODS

Six hundred seventy-four women presenting for routine elective first-trimester abortions were studied. All were 84 or fewer days after the last menstrual period, had no history of bleeding, and had positive urine pregnancy tests. Each woman was scanned initially with an empty-bladder transabdominal technique. If no sac was seen, endovaginal ultrasonography was performed. All terminations had modified gross examination of tissue (3x magnification) as well as staining for microscopic analysis.

RESULTS

Six hundred twelve patients (90.8%) demonstrated intrauterine gestations on transabdominal ultrasound, 595 of which were 12 or fewer weeks. Suction and sharp curettage and examination of tissue revealed products of conception in all. Seventeen subjects (2.5%) were found to be 13 or more weeks despite bimanual examinations and last menstrual period suggesting 12 or fewer weeks. Sixty-two patients had no sac seen on transabdominal ultrasound, 34 of whom had definitive intrauterine gestations on endovaginal ultrasound. Curettage revealed chorionic villi in all. Two had unruptured definitive ectopic pregnancies seen on endovaginal ultrasound. Twenty-one women with no sac seen on endovaginal ultrasound underwent curettage as the next step in triage; chorionic villi proved an intrauterine gestation in 17. The additional four had decidua only on pathology. Rising hCG levels in two of these four led to a diagnosis of ectopic pregnancy, whereas falling hCG levels in the other two led to a presumptive diagnosis of complete abortion, possibly tubal pregnancy in light of the lack of vaginal bleeding.

CONCLUSION

Pre-abortion sonography eliminates inadvertent second-trimester cases, and immediate postoperative examination of curettage material expedites the diagnosis of ectopic pregnancy when present.

Symptomatic non-insulin-dependent diabetes mellitus during therapy with recombinant human growth hormone

In a 12-year-old girl, hyperglycemia and an elevated glycohemoglobin concentration developed after therapy with growth hormone for familial short stature. Both clinical and biochemical abnormalities disappeared after therapy was discontinued. The insulin response to an oral glucose tolerance test was abnormal 3 months after discontinuation of growth hormone; 18 months later, it remained delayed but was normal quantitatively.

Growth deficits in children treated with desipramine: a controlled study

Using multiple assessment methods, growth deficits in weight and height were examined in a clinical sample of children and adolescents with attention deficit hyperactivity disorder treated chronically (mean 14 months) with desipramine (DMI) and two comparison samples of children treated chronically with methylphenidate (MPH) and a not-treated group. Although there were statistically significant weight deficits in children treated with both DMI and MPH compared with normal controls, only those treated with MPH sustained height deficits that attained statistical significance. It appears that DMI may be an appropriate alternative for patients with stimulant-associated severe suppression of growth in height.

Very early pregnancy detection with endovaginal ultrasound

There are many situations in which the earliest possible detection of an intrauterine pregnancy would enhance clinical management. Current radioimmunoassays for hCG can detect pregnancy as early as eight to 12 days post-conception. The ability to document an intrauterine pregnancy with ultrasound has lagged behind by two to three weeks. New high-frequency endovaginal transducers offer the promise of narrowing this gap. This study was undertaken prospectively on 235 patients all amenorrheic for seven weeks or less and requesting either pregnancy testing or termination. All had endovaginal ultrasound scans. We obtained hCG levels when no sac was seen or when the sac was less than 1.0 cm (initial experience revealed that all sacs over 1.0 cm were associated with hCG levels over 6000 mIU/mL) (International Reference Preparation). Ultrasound findings were correlated with pathology specimens and/or hCG levels where appropriate. Results indicated that normal pregnancies can be imaged when: 1) The sac is greater than 0.4 cm; 2) hCG is greater than 1025 mIU/mL (International Reference Preparation); and 3) the uterus is normal with a homogeneous echo pattern. This was not true in three of our cases with diffuse myomatous changes or a coexisting intrauterine device.

Dynamics of bioactive luteinizing hormone-human chorionic gonadotropin during the first 7 days of life

Serum luteinizing hormone-human chorionic gonadotropin bioactivity (B-LH) was measured daily in seven male and four female full-term newborns during the first 7 days of life. The B-LH levels were elevated in both sexes during the 1st day of life; subsequently, values decreased in both sexes. In males, they reached a nadir on the 4th day of life. A gradual secondary rise was then observed with B-LH levels on the 7th day significantly higher than on day 4 (p less than 0.025). By contrast, the B-LH levels in the females continued a gradual decline to levels significantly lower on day 7 as compared to day 4 (p less than 0.05). To determine whether pulsatile B-LH secretion occurs in newborns, serum concentrations were measured every 20 min for 2 h in eight male and seven female full-term neonates on the 7th day of life. Pulsatile secretion of B-LH was detected in six males and six females. This study demonstrates that pulsatility of gonadotropin secretion is characteristic of neonates as early as 7 days of life and that there is a dichotomy between the levels of B-LH in males and females; levels in females decline progressively from day 1 through 7, whereas in males, a nadir is reached on day 4 with a secondary rise developing thereafter. This male sex-specific rise is presumably the drive responsible for the characteristic postnatal increase in testosterone which peaks at 1 to 2 months of age.

Combined sonographic-pathologic surveillance in elective first-trimester termination of pregnancy

In this study, we attempted to develop a surveillance protocol for elective first-trimester termination to see whether unsuspected ectopic pregnancy could be detected earlier, and to identify those patients with unsuspected second-trimester pregnancies that could be terminated more safely in the hospital. Two hundred fifty consecutive patients requesting elective termination were studied prospectively. All were 12 weeks or less by last menstrual period, had positive urinary pregnancy tests, and had no history of vaginal bleeding. All patients had ultrasound screening before curettage. Immediately after curettage, a "modified" gross pathologic examination (3X magnification) was also performed on unstained curettage material. The sonographic, operative, and pathologic findings were all correlated. Such screening identified four patients with unruptured ectopic pregnancies, who were operated on the same day as the curettage. In addition, four patients, who were actually in the second trimester but had inaccurate dates, were identified and referred to hospital for appropriate methods of termination. We conclude that such surveillance may reduce morbidity in elective terminations and more rapidly identify unsuspected ectopic pregnancies.

Behavioral and psychodynamic approaches to milieu therapy in an adolescent day hospital

The day-hospital concept had its beginning in the 1930s and has gained greater impact in recent years because of changes in public-health policy and in traditional psychiatric attitudes. The main therapeutic medium of day hospitals is based on an original concept combining treatment and readaptation in a specially designed therapeutic milieu. A therapeutic milieu is built according to a given theoretical approach. At the Geha Psychiatric Hospital in Petah Tiqva, Israel, the day-care department for adolescents is built according to a combination of the behaviorist and psychoanalytical approaches.

Cushing's syndrome and acute lymphoblastic leukemia

Cushing's disease developed in a 5-year-old girl with acute lymphoblastic leukemia 18 months after her last therapeutic exposure to adrenal glucocorticosteroids. Obesity, hyperpigmentation, striae, osteoporosis, and hirsutism were accompanied by elevated levels of plasma cortisol. These showed no diurnal fluctuation and they were not suppressed by dexamethasone. At autopsy, the adrenal glands were enlarged and the pituitary gland showed increased numbers of basophils of the adrenocorticotropic hormone (ACTH)/melanocyte-stimulating hormone secreting type. Leukemic infiltrates in brain tissue were prominent in the hypothalamus and in the limbic system. It is postulated that the destructive leukemic infiltrate of the limbic system removed a restraining influence on pituitary function, with basophilic hyperplasia, ACTH hypersecretion, adrenocortical hypertrophy, and clinical Cushing's disease the consequences.

Sexual precocity in a male due to thoracic polyembryoma

A 7-year-old boy with sexual precocity of recent onset was found to have elevated levels of chorionic gonadotropin, alpha fetoprotein, and testosterone. Removal of a retropleural, posterior mediastinal mass with an intraspinous epidural extension was followed by prompt declines in the plasma concentrations of the tumor markers and cessation of adolescent development. The neoplasm proved to be a polyembryoma, unusual in the multiplicity of its embryoid bodies and extra gonadal location. Following local irradiation and two years of systemic chemotherapy, the patient, now 13 years of age, has done well except for evidence of testicular tubular insufficiency.

Premature adrenarche in indentical twins

Monozygotic female twins with premature adrenarche are reported. Endocrine work-up excluded the existence of an endocrinopathy or a tumor.

Cushing syndrome, sexual precocity, and polyostotic fibrous dysplasia (Albright syndrome) in infancy

The sexual precocity of polyostotic fibrous dysplasia is occasionally accompanied by other endocrine disorders, but in only two previous instances has Cushing syndrome been reported. The history of a 6-month-old girl is presented, in whom this syndrome was complicated by congenital Cushings syndrome. Although endocrinopathies of polyostotic fibrous dysplasia have usually been ascribed to a central (hypothalamic) origin, the findings in this patient suggest autonomous hyperfunction of the peripheral endocrine glands, with the Cushing syndrome caused by hyperplastic nodules in the adrenal glands and the precocity by luteinized follicular cysts of the ovary.

Partial target organ resistance to thyroid hormone

An 8-year old boy with a small goiter, normal basal metabolic rate (BMR), and elevated serum thyroid hormone levels (thyroxine [T(4)] 19.5 mug per 100 ml, free T(4) 4 ng per 100 ml, triiodothyronine [T(3)] 505 ng per 100 ml) was studied. He had measurable serum thyroid-stimulating hormone (TSH) levels (average 5.5 muU per ml), and the thyroxine-binding proteins, hearing, and epiphyseal structures were normal. There was no parental consanguinity nor were there thyroid abnormalities either in the parents or six siblings.Methimazole, 50 mg daily, depressed thyroxine synthesis (T(4) 10.5, free T(4) 2.5) and caused a rise in TSH to 11 muU per ml. After discontinuation of treatment, TSH declined to 4.2 muU per ml and chemical hyperthyroidism returned (T(4) 21.0 mug per 100 ml, free T(4) 4.2, and total T(3) 475 ng per 100 ml, radioactive iodine [RAI] uptake 68%), but studies of BMR and insensible water loss showed the patient to be clinically euthyroid. Thyrotropin-releasing hormone (TRH), 200 mug i.v., caused a brisk rise in TSH to 28 muU per ml, with T(4) rising to 28 mug per 100 ml, free T(4) to 5.6, and T(3) to 730 ng per 100 ml, thus indicating that the pituitary-thyroid system was intact and that the patient's TSH was biologically active. The unusual sensitivity of the pituitary cells to TRH in spite of the markedly elevated serum thyroid hormone levels also suggested that the pituitary was insensitive to suppression by T(3) or T(4). Serum dilution studies gave immunochemical evidence that this patient's TSH was normal. Neither propranolol, 60 mg, chlorpromazine, 30 mg, nor prednisone, 15 mg daily, influenced thyroid indices. Steroid treatment, however, suppressed the pituitary response to TRH, T(3) in doses increased over a period of 12 days to as much as 150 mug daily caused a rise in serum T(3) to above 800 ng per 100 ml, a decline of T(4) to euthyroid levels (T(4) 9.5 mug per 100 ml, free T(4) 1.6 ng per 100 ml), suppression of the RAI uptake from 68% to 35%, and marked blunting of the responses to TRH, but the BMR and insensible water loss remained normal. The data suggest that the patient's disorder is due to partial resistance to thyroid hormone.