Acute Dissociation and Ketamine's Antidepressant and Anti-Suicidal Ideation Effects in a Midazolam-Controlled Trial

OBJECTIVE

We sought to explore relationships of acute dissociative effects of intravenous ketamine with change in depression and suicidal ideation and with plasma metabolite levels in a randomized, midazolam-controlled trial.

METHODS

Data from a completed trial in suicidal, depressed participants (n = 40) randomly assigned to ketamine was used to examine relationships between ketamine treatment-emergent dissociative and psychotomimetic symptoms with pre/post-infusion changes in suicidal ideation and depression severity. Nonparametric correlational statistics were used. These methods were also used to explore associations between dissociative or psychotomimetic symptoms and blood levels of ketamine and metabolites in a subset of participants (n = 28) who provided blood samples immediately post-infusion.

RESULTS

Neither acute dissociative nor psychotomimetic effects of ketamine were associated with changes in suicidal ideation or depressive symptoms from pre- to post-infusion. Norketamine had a trend-level, moderate inverse correlation with dissociative symptoms on Day 1 post-injection (P  = .064; P =.013 removing 1 outlier). Dehydronorketamine correlated with Clinician-Administered Dissociative States Scale scores at 40 minutes (P = .034), 230 minutes (P = .014), and Day 1 (P = .012).

CONCLUSION

We did not find evidence that ketamine's acute, transient dissociative, or psychotomimetic effects are associated with its antidepressant or anti-suicidal ideation actions. The correlation of higher plasma norketamine with lower dissociative symptoms on Day 1 post-treatment suggests dissociation may be more an effect of the parent drug.

Intramuscular ketamine vs. midazolam for rapid risk-reduction in suicidal, depressed emergency patients: Clinical trial design and rationale

Emergency department (ED) visits for suicidal ideation or behavior have been increasing in all age groups, particularly younger adults. A rapid-acting treatment to reduce suicidal thinking, adapted for ED use, is needed. Previous studies have shown a single dose of ketamine can improve depression and suicidal ideation within hours. However, most studies used 40 min intravenous infusions which can be impractical in a psychiatric ED. The ER-Ketamine study we describe here is a randomized midazolam-controlled clinical trial (RCT; NCT04640636) testing intramuscular (IM) ketamine's feasibility, safety, and effectiveness to rapidly reduce suicidal ideation and depression in a psychiatric ED. A pre-injection phase involves screening, informed consent, eligibility confirmation, and baseline assessment of suicidal ideation, depression, and comorbidities. The randomized double-blind IM injection is administered in the ED under research staff supervision, vital sign monitoring, pharmacokinetic blood sampling, and clinical assessments. The post-injection phase occurs on a psychiatric inpatient unit with follow-up research assessments through four weeks post-discharge. Outcome measures are feasibility, safety, and effects on suicidal ideation and depression at 24 h post-injection, and through follow-up. The target sample is N = 90 adults in a major depressive episode, assessed by ED clinicians as warranting hospitalization for suicide risk. Here we report design, rationale, and preliminary feasibility and safety for this ongoing study. Demographics of the 53 participants (ages 18 to 65 years) randomized to date suggest a diverse sample tending towards younger adults.

Racial and ethnic disparities in time to first antidepressant medication or psychotherapy

Time from first DSM4 major depressive episode (MDE) until treatment in the community was compared across racial/ethnic groups. This secondary analysis used structured baseline data from a depression research clinic (N = 260). Chi-square and survival analyses compared rates and delays to antidepressant medication and psychotherapy. Non-Hispanic Black and Hispanic (any race) participants had lower rates of both antidepressant medication and psychotherapy and longer delays to antidepressant medication compared with non-Hispanic White participants. The results underscore the need to reduce these disparities.

Effects of familiar music exposure on deliberate retrieval of remote episodic and semantic memories in healthy aging adults

Familiar music facilitates memory retrieval in adults with dementia. However, mechanisms behind this effect, and its generality, are unclear because of a lack of parallel work in healthy aging. Exposure to familiar music enhances spontaneous recall of memories directly cued by the music, but it is unknown whether such effects extend to deliberate recall more generally - e.g., to memories not directly linked to the music being played. It is also unclear whether familiar music boosts recall of specific episodes versus more generalised semantic memories, or whether effects are driven by domain-general mechanisms (e.g., improved mood). In a registered report study, we examined effects of familiar music on deliberate recall in healthy adults ages 65-80 years (N = 75) by presenting familiar music from earlier in life, unfamiliar music, and non-musical audio clips across three sessions. After each clip, we assessed free recall of remote memories for pre-selected events. Contrary to our hypotheses, we found no effects of music exposure on recall of prompted events, though familiar music evoked spontaneous memories most often. These results suggest that effects of familiar music on recall may be limited to memories specifically evoked in response to the music (Preprint and registered report protocol at https://osf.io/kjnwd/).

Early Versus Delayed Treatment for Gartland Type III Supracondylar Humeral Fractures in Children: A Systematic Review and Meta-analysis

PURPOSE

The timing of treatment for Gartland type III supracondylar fractures has been an area of contention as it was previously thought to be a surgical emergency. The aim of this systematic review and meta-analysis is to clarify whether there is a difference in perioperative outcomes between early and delayed treatment for Gartland type III supracondylar humeral fractures in children.

METHODS

Literature search and study selection were performed according to the PRISMA process. The early surgery (ES) and delayed surgery (DS) groups were defined by the authors of each study included, based on the time to surgery. The primary outcome was the risk of conversion to open reduction. The secondary outcome was perioperative complication risks.

RESULTS

A total of 14 studies met the eligibility criteria (n = 1263 patients), of which 665 (52.7%) patients had undergone early surgery, while 598 (47.3%) had delayed surgery. On meta-analysis, there was no significant difference between ES and DS for the outcome of open reduction conversion risk. There was also no significant difference for the secondary outcomes of post-operative compartment syndrome, iatrogenic nerve injury, vascular injury, and surgical site infection.

CONCLUSION

Despite the limitations in the literature, evidence exists to support the notion that a delayed approach to the surgical treatment of Gartland type III supracondylar humeral fractures in children does not result in an increased risk of converting to open reduction and perioperative complications.

Ameliorative effect of metformin on cyclophosphamide-induced memory impairment in mice

OBJECTIVE

Cyclophosphamide (CYP) is a chemotherapeutic agent that is widely used as an adjuvant cancer treatment. Unfortunately, this drug is associated with secondary side effects, including cognitive impairment up to 70% of cancer survivors. The mechanism of this memory impairment is unclear. Thus, to understand the cognitive impairments caused by this chemotherapeutic agent, a clinically relevant dose to cancer treatment was used in mice to establish the chemobrain models, and the spatial memory of these mice was assessed using multiple behavior tests. In addition, metformin (MET) is widely used as an anti-diabetic drug and protects against oxidative stress and hepatotoxicity. Thus, this study tested the protective effects of MET in the chemobrain models.

MATERIALS AND METHODS

Four groups of mice, which weighed about 18-30 g, were collected and divided into 4 groups: control, CYP, MET, and CYP+MET groups. A 100 mg/kg dose of CYP was administered intraperitoneal (on alternate days) for a total of 4 doses. MET was dissolved in the mice's drinking water bottles at a 5 mg/ml concentration from day zero to the end of the treatment period. The mice's memory was tested using hippocampal-dependent tests, including the Y-maze, novel object recognition, and elevated plus maze tests. These tests were performed for three consecutive days after 24 h of the last dose of CYP.

RESULTS

The mice treated with CYP exhibited a decline in memory function in all the behavioral test studies, and this decline was significant in the Y-maze test. However, this decline was rescued by MET administration.

CONCLUSIONS

The clinically relevant model suggests that CYP treatment causes a decline in mice models spatial memory that might be improved by MET administration.

Po uptake in microalgae at different seawater pH: An experimental study simulating ocean acidification

Climate change effects such as ocean acidification (OA) are known to affect the trace metal distribution. This experimental study provides the first data on ²⁰⁹Po uptake rates and ²¹⁰Po concentration in five microalgae species under different pH scenarios. The experiment was conducted in replicates at three pH conditions 8.2, 8.0, and 7.5, representing the current and future climate change scenario as per IPCC RCP8.5. The ²⁰⁹Po uptake in the phytoplankton was highest in Thalassiosira weissflogi, i.e. 83% of the ²⁰⁹Po tracer was taken up at 8.2 pH whereas the lowest uptake was observed in Dunaliella salina equivalent to 20% at 7.5 pH. Similar behavior was observed in ²¹⁰Po concentrations in these microalgae, where ²¹⁰Po ranged between 3.16 ± 0.03 and 11.6 ± 0.04 Bq kg^-1 wet weight (ww), with the highest in the Thalassioria weissflogi at 8.2 pH, and the lowest in Dunaliella salina at 7.5 pH. The difference in ²⁰⁹Po uptake and ²¹⁰Po concentration was statistically significant (p < 0.001) both among species and the pH treatments in the order: Thalassiosira weissflogi > Tetraselmis suecica > Chaetoceros muelleri > Isochrysis galbana > Dunaliella salina and 8.2 > 8.0 > 7.5. A higher concentration of ²⁰⁹Po in seawater was measured at low pH condition in all the experimental tanks. Though the data clearly show the difference in concentration and uptake of polonium at different pH conditions, it is not known if lower pH is affecting the adsorbed or absorbed fraction. A detailed investigation will be required to understand the process as it can have a significant effect on biomagnification and marine food chain transfer under changing climatic scenarios.

Concentration of 210Po and 210Pb in macroalgae from the northern Gulf

This baseline study highlights the 210Po and 210Pb concentration in seven macroalgae species from the northern Gulf that are frequently washed ashore during the bloom season from February to April. The highest concentrations of 210Po and 210Pb were 2.947 ± 0.032 and 1.057 ± 0.145 Bq kg-1 wwt, respectively, in brown algae Sargassum boveanum, and the lowest in green algae Ulva prolifera with 1.533 ± 0.058 and 0.170 ± 0.069 Bq kg-1 wwt, respectively. A 210Po enrichment was observed in both brown and green algae species, with the 210Po/210Pb ratio being >1 for all the samples. The mean concentration of 210Po in all species was an order of magnitude higher than 210Pb, and the difference in mean concentration is statistically significant (p < 0.001). At the same time, the mean concentration of dissolved 210Po and 210Pb in seawater was 0.28 ± 0.01 and 0.52 ± 0.01Bq m-3 with a 210Po/210Pb ratio of 0.54 ± 0.02 indicating that 210Po was absorbed from water and more concentrated by macroalgae. The measured concentration factor (CF) for 210Po in these macroalgae for the northern Gulf varied between 5 × 103-1 × 104, higher than the IAEA recommended value of 1 × 103 which suggests that a revision of that value may be needed. The field derived CFs for 210Pb vary between 3 × 102-1.8 × 103, comparable to the ICRP recommended value of 2 × 103.

210Po concentration in selected diatoms and dinoflagellates in the northern Arabian Gulf

Marine phytoplankton is a primary producer in the ocean that forms the base of the marine food web and supports the pelagic food chain. The two dominant groups of phytoplankton observed in northern Gulf waters are diatoms and dinoflagellates. The diatoms outnumber dinoflagellates in the Gulf waters. This study presents baseline information on the concentration of ²¹⁰Po among selected phytoplankton in the northern Gulf. The concentration among diatoms varies between 6.99 and 11.4 Bq kg^-1 wwt, whereas a higher concentration range of 8.51-15.41 Bq kg^-1 wwt was observed among dinoflagellates. The diatoms analyzed includes Thalassiosira spp. - 10.2-11.4 Bq kg^-1 wwt; Chaetoceros spp. - 6.99-7.14 Bq kg^-1 wwt; Rhizosolenia spp. - 9.12-9.95 Bq kg^-1 wwt. The analyzed dinoflagellate genera include Gymnodinium spp. - 8.51-8.78 Bq kg^-1 wwt; Noctiluca spp. - 15.2-15.4 Bq kg^-1 wwt; and Karenia spp. - 14.1-14.9 Bq kg^-1 wwt. The ²¹⁰Po concentration in seawater shows a seasonal variation, with a higher concentration range of 0.70 and 0.58 mBq L^-1 during summer and autumn, whereas a lower range in concentration of 0.38 and 0.30 mBq L^-1 occurring during winter and spring. The resultant computed concentration factors vary between 2 ∗ 10⁴-5 ∗ 10⁴ demonstrating a significant ²¹⁰Po enrichment in the base of the pelagic food chain.

Outcomes of involuntary hospital admission. Satisfaction with treatment and the effect of involuntary admissions on patients

Introduction

Involuntary hospitalization in those presumed to be mentally ill has been a common practice. Although some patients are hospitalized for aggression, two-thirds of the patients are hospitalized because of the threat they pose to themselves. Although these patients require risk assessment and evaluation for possible presence of mental illness, the question is how much these patients will benefit from involuntary admission and what the long-term outcome would be.

Method

All patients admitted involuntary to the psychiatric ward in Kingston, Canada, and psychiatrists involved in their care were interviewed to see whether they think the involuntary admission was helpful. All patients were asked to fill-out MacArthur AES to assess their satisfaction with hospitalization.

Results

Although psychiatrists frequently reported that the admission was justified, only 29 out of 81 patients reported being explained to why they had been admitted involuntarily. Also, there was a significant difference in AES scores between those who were and were not given an explanation for admission. In addition, psychiatrists more often reported that the involuntary admission worsened the therapeutic relationship which was significantly associated with involuntary admission that was not explained to patients.

Discussion

The results of our study shows that patients admitted involuntarily often feel disappointed with staff and mental health system. It could lead to feeling of hopelessness, frustration and low self-esteem. If explained, some patients who present with risk to self might accept voluntary admissions, that will improve therapeutic alliance with psychiatrists and increase satisfaction from hospitalization. Result of this study could improve the decision making process for involuntary admissions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Autoimmune haemolytic anaemia due to Omeprazole

A 72-year-old lady who was prescribed Omeprazole for gastroesophageal reflux developed an allergic reaction within two days, which manifested initially as a generalised rash and marked eosinophilia. This was followed by a fall in haemoglobin without any obvious bleeding. Investigations pointed to drug related intravascular haemolysis as the cause. She made an uneventful recovery after omitting Omeprazole and treatment with steroids. Omeprazole should be considered amongst other recognised causes of drug-induced haemolysis

The dual-wave bolus feature in continuous subcutaneous insulin infusion pumps controls prolonged post-prandial hyperglycaemia better than standard bolus in Type 1 diabetes

The dual-wave bolus delivers a combination of an immediate normal pre-meal insulin bolus (approximately 3 min) followed by an extended (or square-wave) bolus that is evenly delivered over several hr as programmed by the patient. The purpose of this study was to compare post-prandial glycaemic excursions following a high-fat meal after administration of insulin by normal vs dual-wave bolus. During this prospective, cross-over, repeated measures study, subjects with diabetes and treated with insulin pump therapy were evaluated using the continuous glucose monitoring system (CGMS) following three combinations of meal and bolus type. A control meal or a high-fat meal was given in place of the evening meal on three separate occasions and comparisons were made between: a) the control meal with normal insulin bolus delivery, b) the high-fat meal with normal insulin bolus delivery, and c) the high-fat meal with dual-wave insulin bolus delivery. Although mean baseline CGMS values were similar in each of the three combinations of meal and bolus type (p=0.54) and in the three hr immediately following the meal (p=0.64, p=0.83, p=1.0), when compared to the control meal/normal bolus and high-fat meal/dual-wave bolus combinations, CGMS profiles disclosed significantly elevated post-prandial glucose in hr 5 through 14 (p<0.05) following the high-fat/normal bolus combination. Prolonged post-prandial glycaemic excursions are identified using the CGMS. Treating post-prandial hyperglycaemia with dual-wave insulin delivery may help manage chronic hyperglycaemia in patients with diabetes.