Noninvasive Surrogate for Physiologic Dead Space Using the Carbon Dioxide Ventilatory Equivalent: Testing in a Single-Center Cohort, 2017-2023

OBJECTIVES

We sought to evaluate the association between the carbon dioxide (co2) ventilatory equivalent (VEqco2 = minute ventilation/volume of co2 produced per min), a marker of dead space that does not require a blood gas measurement, and mortality risk. We compared the strength of this association to that of physiologic dead space fraction (VD/Vt = [Paco2-mixed-expired Pco2]/Paco2) as well as to other commonly used markers of dead space (i.e., the end-tidal alveolar dead space fraction [AVDSf = (Paco2-end-tidal Pco2)/Paco2], and ventilatory ratio [VR = (minute ventilation × Paco2)/(age-adjusted predicted minute ventilation × 37.5)]).

DESIGN

Retrospective cohort data, 2017-2023.

SETTING

Quaternary PICU.

PATIENTS

One hundred thirty-one children with acute respiratory distress syndrome.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All dead space markers were calculated at the same 1-minute timepoint for each patient within the first 72 hours of using invasive mechanical ventilation. The 131 children had a median (interquartile range, IQR) age of 5.8 (IQR 1.4, 12.6) years, oxygenation index (OI) of 7.5 (IQR 4.6, 14.3), VD/Vt of 0.47 (IQR 0.38, 0.61), and mortality was 17.6% (23/131). Higher VEqco2 (p = 0.003), VD/Vt (p = 0.002), and VR (p = 0.013) were all associated with greater odds of mortality in multivariable models adjusting for OI, immunosuppressive comorbidity, and overall severity of illness. We failed to identify an association between AVDSf and mortality in the multivariable modeling. Similarly, we also failed to identify an association between OI and mortality after controlling for any dead space marker in the modeling. For the 28-day ventilator-free days outcome, we failed to identify an association between VD/Vt and the dead space markers in multivariable modeling, although OI was significant.

CONCLUSIONS

VEqco2 performs similarly to VD/Vt and other surrogate dead space markers, is independently associated with mortality risk, and may be a reasonable noninvasive surrogate for VD/Vt.

High intensity interval training exercise increases dopamine D2 levels and modulates brain dopamine signaling

Background

Previous research has outlined the health benefits of exercise including its therapeutic potential for substance use disorders (SUD). These data have already been utilized and it is now common to find exercise as part of SUD treatment and relapse prevention programs. However, we need to better understand different exercise regimens and determine which would be the most beneficial for SUDs. Recently, high intensity interval training (HIIT) has gained attention in comparison with aerobic and resistance exercise. Little is known regarding the neurobiological mechanisms of HIIT, including its effects on dopamine signaling and receptor levels in the brain. The present study examined the effects of chronic HIIT exercise on dopamine signaling as measured by dopamine type 1-like receptor (D1R)-like, dopamine type 2-like receptor (D2R)-like, and tyrosine hydroxylase (TH) quantification in the brains of male and female rats as measured by [3H] SCH 23390 and [3H] spiperone autoradiography, and TH-immunoreactive optical density values.

Methods

Rats were separated in two groups: sedentary and HIIT exercise. Exercise was on a treadmill for 30 min daily (10 3 min cycles) for six weeks with progressive speed increased up to 0.8 mph (21.5 m/min).

Results

Results showed for D2R-like binding, a significant effect across the ventral caudate putamen (V CPU) between sexes, such that mean D2R-like binding was 14% greater for males than females. In the nucleus accumbens shell (Nac Shell), the HIIT Exercise rats showed 16% greater D2R-like binding as compared to the sedentary rats. No significant effects of HIIT exercise were found across groups for brain D1R-like binding levels or TH expression.

Conclusion

These results suggest that HIIT exercise can modulate dopamine signaling by way of increased D2R. These findings support the premise that HIIT exercise plays an important role in dopamine signaling and, may provide a potential mechanism for how HIIT exercise can impact the brain and behavior.

Longitudinal, prospective study of head impacts in male high school football players

INTRODUCTION

Repetitive, subconcussive events may adversely affect the brain and cognition during sensitive periods of development. Prevention of neurocognitive consequences of concussion in high school football is therefore an important public health priority. We aimed to identify the player positions and demographic, behavioral, cognitive, and impact characteristics that predict the frequency and acceleration of head impacts in high school football players.

METHODS

In this prospective study, three cohorts of adolescent male athletes (N = 53, 28.3% Hispanic) were recruited over three successive seasons in a high school American football program. Demographic and cognitive functioning were assessed at baseline prior to participating in football. Helmet sensors recorded impact frequency and acceleration. Each head impact was captured on film from five different angles. Research staff verified and characterized on-field impacts. Player-level Poisson regressions and year-level and impact-level linear mixed-effect models were used to determine demographic, behavioral, cognitive, and impact characteristics as predictors of impact frequency and acceleration.

RESULTS

4,678 valid impacts were recorded. Impact frequency positively associated with baseline symptoms of hyperactivity-impulsivity [β(SE) = 1.05 impacts per year per unit of symptom severity (1.00), p = 0.01] and inattentiveness [β(SE) = 1.003 impacts per year per T-score unit (1.001), p = 0.01]. Compared to quarterbacks, the highest acceleration impacts were sustained by kickers/punters [β(SE) = 21.5 g's higher (7.1), p = 0.002], kick/punt returners [β(SE) = 9.3 g's higher (4.4), p = 0.03], and defensive backs [β(SE) = 4.9 g's higher (2.5), p = 0.05]. Impacts were more frequent in the second [β(SE) = 33.4 impacts (14.2), p = 0.02)] and third [β(SE) = 50.9 impacts (20.1), p = 0.01] year of play. Acceleration was highest in top-of-the-head impacts [β(SE) = 4.4 g's higher (0.8), p<0.001].

CONCLUSION

Including screening questions for Attention-Deficit/Hyperactivity Disorder in pre-participation evaluations can help identify a subset of prospective football players who may be at risk for increased head impacts. Position-specific strategies to modify kickoffs and correct tackling and blocking may also reduce impact burden.

Psychedelics, With a Focus on Psilocybin: Issues for the Clinician

There has been a burgeoning interest in psychedelics among the public, state legislatures, psychiatrists and other clinical providers, and within the research community. Increasing numbers of studies evaluating psychedelics for depression, anxiety, posttraumatic stress disorder, and substance use disorders have been conducted or are underway. While discussing psychedelics in general, the focus of this paper is on psilocybin and its mechanism, how it exerts a psychedelic effect, dosing, and a review of the treatment studies of psilocybin, which were primarily for treatment-resistant depression and cancer-related anxiety. Future directions and potential limitations of studying and regulating psilocybin and other psychedelics are also discussed.

Effects of exercise on mortality rates of individuals with severe mental illness

Persons with severe mental illness have a 10-to-20-year shorter life span than the general public. Excess morbidity and mortality in this patient population has been described as a major public health challenge worldwide. Despite robust extant literature on the role of exercise in reducing morbidity and mortality, especially from cardiovascular disease and diabetes (highly prevalent in this patient population), Very few clinical programs or clinical research projects currently exist to implement and study the effects of exercise on decreasing morbidity and mortality in this highly vulnerable patient population. Given the global lack of trained mental health providers, the need to integrate healthcare providers from different disciplines, such as nurses, physical therapists, occupational therapists, physician assistants, cannot be overstated. This mini-review will provide an historic perspective and current data supporting the need to establish exercise, and other Lifestyle Psychiatry interventions, as a key component of treatment for all patients with serious mental illness.

Remdesivir for the Treatment of COVID-19: A Systematic Review of the Literature

In March 2020, the World Health Organization declared the spread of SARS-CoV-2 a global pandemic. To date, coronavirus disease-2019 (COVID-19) has spread to over 200 countries, leading to over 1.6 million cases and over 99,000 deaths. Given that there is neither a vaccine nor proven treatment for COVID-19, there is currently an urgent need for effective pharmacotherapy. To address the need for an effective treatment of SARS-CoV-2 during the worldwide pandemic, this systematic review of intravenous (IV) remdesivir was performed. Remdesivir, an anti-viral prodrug originally developed to treat Ebola virus disease, has shown broad spectrum activity against the Coronavirus family. A recent case report reported improvement of clinical symptoms with remdesivir in a patient with COVID-19. After conducting a systematic search of 18 clinical trial registries and three large scientific databases, we identified 86 potentially eligible items. Following removal of duplicates (n = 21), eligible studies were reviewed independently by two authors. After the first round of screening, inter-rater agreement was 98.5% (κ = 0.925). After the second round of full-text screening, inter-rater agreement was 100%. A total of seven ongoing and recruiting clinical trials of remdesivir (100–200 milligrams, intravenous [IV]) were included. We identified the following primary outcomes: patients discharged (n = 2); time to clinical status improvement (n = 2); improved O2 saturation (n = 2); body temperature normalization (n = 2); and clinical status (n = 1). Secondary outcomes in all identified studies included documentation of adverse events. Phase 3 trials are expected to be completed between April 2020–2023. Therefore, despite supportive data from in vitro and in vivo studies, the clinical effectiveness of IV remdesivir for treatment of COVID-19 and potential side effects remain incompletely defined in the human population.

ENIGMA and global neuroscience: A decade of large-scale studies of the brain in health and disease across more than 40 countries

This review summarizes the last decade of work by the ENIGMA (Enhancing NeuroImaging Genetics through Meta Analysis) Consortium, a global alliance of over 1400 scientists across 43 countries, studying the human brain in health and disease. Building on large-scale genetic studies that discovered the first robustly replicated genetic loci associated with brain metrics, ENIGMA has diversified into over 50 working groups (WGs), pooling worldwide data and expertise to answer fundamental questions in neuroscience, psychiatry, neurology, and genetics. Most ENIGMA WGs focus on specific psychiatric and neurological conditions, other WGs study normal variation due to sex and gender differences, or development and aging; still other WGs develop methodological pipelines and tools to facilitate harmonized analyses of "big data" (i.e., genetic and epigenetic data, multimodal MRI, and electroencephalography data). These international efforts have yielded the largest neuroimaging studies to date in schizophrenia, bipolar disorder, major depressive disorder, post-traumatic stress disorder, substance use disorders, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, autism spectrum disorders, epilepsy, and 22q11.2 deletion syndrome. More recent ENIGMA WGs have formed to study anxiety disorders, suicidal thoughts and behavior, sleep and insomnia, eating disorders, irritability, brain injury, antisocial personality and conduct disorder, and dissociative identity disorder. Here, we summarize the first decade of ENIGMA's activities and ongoing projects, and describe the successes and challenges encountered along the way. We highlight the advantages of collaborative large-scale coordinated data analyses for testing reproducibility and robustness of findings, offering the opportunity to identify brain systems involved in clinical syndromes across diverse samples and associated genetic, environmental, demographic, cognitive, and psychosocial factors.

Notions of Preprocedural Patient Anxiety in the Realm of IR

PURPOSE

To determine the views and current practice preferences of interventional radiologists and allied healthcare providers regarding management of preprocedural anxiety.

MATERIALS AND METHODS

From March to April 2018, members of the Society of Interventional Radiology were surveyed regarding their opinions in the assessment and management of patient anxiety. Degree of responsibility for the management of anxiety was also queried through the use of a scale (1 = no responsibility; 2 = some responsibility; 3 = major responsibility).

RESULTS

Of 1163 respondents (23.8% response rate), most described preprocedural anxiety as somewhat to very important in their practice (n = 961, 82.6%), somewhat to very important to the patients (n = 1087, 93.5%), and at least sometimes interfering with delivery of care (n = 815, 70.1%). Most respondents did not measure preprocedural anxiety directly (n = 953, 81.9%), but would address it if raised by the patient (n = 911, 82.9%). Patient education (n = 921, 79.1%), medications (n = 801, 68.8%), and therapeutic or empathetic interactions (n = 665, 56.4%) were most preferred to manage anxiety. Radiologists, nurses, patients, primary care providers, family members, and psychologists or psychiatrists were all allocated responsibility to reduce anxiety.

CONCLUSIONS

Interventional radiologists and other providers are aware of the importance of preprocedural anxiety. Despite the notion that most radiologists did not address anxiety directly, most indicated a willingness to discuss the issue if raised by patients. Patient education, medications, and several other techniques are preferred to manage preprocedural anxiety. Responsibility to reduce anxiety is perceived to be shared among radiologists, nurses, patients, family members, and other health care providers.

How long does it take to complete outpatient substance use disorder treatment? Disparities among Blacks, Hispanics, and Whites in the US

This research investigates racial and ethnic disparities in outpatient substance use disorder treatment completion and duration in treatment, for different substances, across the US, using the national 2014 Treatment Episode Dataset-Discharge (TEDS-D) data set. Moderated fixed effects logistic regression models assessed effects of race/ethnicity on length of stay in treatment and treatment completion for different substances of use. Moderated models also assessed the differential effect of length of stay on treatment completion among Blacks, Hispanics, and Whites. While Blacks and Hispanics both have significantly lower treatment completion rates than Whites, treatment duration is substantially similar across the three groups. Blacks and Hispanics generally take longer to complete treatment than Whites, though this varies by substance for Hispanics. Disparities in treatment completion persist even after controlling for treatment duration. These results indicate that observed racial and ethnic disparities in treatment completion are not due to differences in length of stay in treatment. Economic, cultural, accessibility, or, potentially, discriminatory, factors may suppress the likelihood of treatment completion for minorities and result in longer treatment durations required for completion. Recognition by treatment providers of the unique challenges to treatment completion faced by minorities may enhance treatment outcomes for minorities in the US.

Neuropsychiatric aspects of concussion

Over the past decade, concussion has become the most widely discussed injury in contact sports. However, concussions also occur in several other settings, such as non-contact sports, elderly individuals, young children, military personnel, and victims of domestic violence. Concussion is frequently undiagnosed as a cause of psychiatric morbidity, especially when the patient has no history of loss of consciousness or direct head trauma. Almost all of the extant literature focuses on traumatic brain injury and assumes that concussion is merely a mild form of traumatic brain injury, which has resulted in a lack of understanding about what concussion is, and how to diagnose, monitor, and treat its varied neuropsychiatric symptoms. In this Review, we address key issues so that the psychiatric clinician can better understand and treat patients with a clinical phenotype that might be the direct result of, or be exacerbated by, concussion. Future research needs to focus on prospective clinical trials in all affected patient populations (ie, those affected by concussion and those affected by various degrees of traumatic brain injury), the identification of reliable biomarkers that can be used to assist with diagnosis and treatment response, and the development of effective treatment interventions. Clearly differentiating concussion from traumatic brain injury is essential to achieve reliable and clinically relevant outcomes.

An International Study of Emotional Response to Bilateral Vision Loss Using a Novel Graphical Online Assessment Tool

BACKGROUND

Leber׳s hereditary optic neuropathy usually causes rapid bilateral blindness in young adults, and thus represents a unique and severe psychologic stressor.

OBJECTIVE

We aimed to describe adjustment to this major life event, using a new tool to enhance recall of past affective states by using life event-related context. This is the largest (n = 116 with Leber׳s hereditary optic neuropathy), and first study reporting on the emotional aspects of this nontrauma cause of blindness.

METHODS

We developed a new online survey tool that allowed study subjects to report their mood over a long period of time, corresponding with dates of relevant life events.

RESULTS

The new method provided data of great richness for qualitative and quantitative analysis. Three groups were identified: a group in which majority of them had severe sadness at the point of vision loss followed by a period of recovery, a group whose sadness had not recovered, and a group for whom vision loss was not a major cause of sadness compared with other life events. We identified numerous factors that were important in psychologic recovery, and premorbid psychologic symptoms were more frequent in those who had not yet recovered.

CONCLUSIONS

These data may assist behavioral health providers in identifying patients with vision loss to be at risk of mental health problems and in developing support and treatment interventions. We believe this new method has great potential for studying psychologic adjustment retrospectively.

A One Health overview, facilitating advances in comparative medicine and translational research

A1 One health advances and successes in comparative medicine and translational research

Cheryl Stroud

A2 Dendritic cell-targeted gorilla adenoviral vector for cancer vaccination for canine melanoma

Igor Dmitriev, Elena Kashentseva, Jeffrey N. Bryan, David T. Curiel

A3 Viroimmunotherapy for malignant melanoma in the companion dog model

Jeffrey N. Bryan, David Curiel, Igor Dmitriev, Elena Kashentseva, Hans Rindt, Carol Reinero, Carolyn J. Henry

A4 Of mice and men (and dogs!): development of a commercially licensed xenogeneic DNA vaccine for companion animals with malignant melanoma

Philip J. Bergman

A5 Successful immunotherapy with a recombinant HER2-expressing Listeria monocytogenes in dogs with spontaneous osteosarcoma paves the way for advances in pediatric osteosarcoma

Nicola J. Mason, Josephine S. Gnanandarajah, Julie B. Engiles, Falon Gray, Danielle Laughlin, Anita Gaurnier-Hausser, Anu Wallecha, Margie Huebner, Yvonne Paterson

A6 Human clinical development of ADXS-HER2

Daniel O’Connor

A7 Leveraging use of data for both human and veterinary benefit

Laura S. Treml

A8 Biologic replacement of the knee: innovations and early clinical results

James P. Stannard

A9 Mizzou BioJoint Center: a translational success story

James L. Cook

A10 University and industry translational partnership: from the lab to commercialization

Marc Jacobs

A11 Beyond docking: an evolutionarily guided OneHealth approach to drug discovery

Gerald J. Wyckoff, Lee Likins, Ubadah Sabbagh, Andrew Skaff

A12 Challenges and opportunities for data applications in animal health: from precision medicine to precision husbandry

Amado S. Guloy

A13 A cloud-based programmable platform for health

Harlen D. Hays

A14 Comparative oncology: One Health in action

Amy K. LeBlanc

A15 Companion animal diseases bridge the translational gap for human neurodegenerative disease

Joan R. Coates, Martin L. Katz, Leslie A. Lyons, Gayle C. Johnson, Gary S. Johnson, Dennis P. O’Brien

A16 Duchenne muscular dystrophy gene therapy

Dongsheng Duan

A17 Polycystic kidney disease: cellular mechanisms to emerging therapies

James P. Calvet

A18 The domestic cat as a large animal model for polycystic kidney disease

Leslie A. Lyons, Barbara Gandolfi

A19 The support of basic and clinical research by the Polycystic Kidney Disease Foundation

David A. Baron

A20 Using naturally occurring large animal models of human disease to enable clinical translation: treatment of arthritis using autologous stromal vascular fraction in dogs

Mark L. Weiss

A21 Regulatory requirements regarding clinical use of human cells, tissues, and tissue-based products

Debra A. Webster

A22 Regenerative medicine approaches to Type 1 diabetes treatment

Francis N. Karanu

A23 The zoobiquity of canine diabetes mellitus, man’s best friend is a friend indeed-islet transplantation

Edward J. Robb

A24 One Medicine: a development model for cellular therapy of diabetes

Robert J. Harman

Geospatial technology and the "exposome": new perspectives on addiction

Addiction represents one of the greatest public health problems facing the United States. Advances in addiction research have focused on the neurobiology of this disease. We discuss potential new breakthroughs in understanding the other side of gene-environment interactions-the environmental context or "exposome" of addiction. Such research has recently been made possible by advances in geospatial technologies together with new mobile and sensor computing platforms. These advances have fostered interdisciplinary collaborations focusing on the intersection of environment and behavior in addiction research. Although issues of privacy protection for study participants remain, these advances could potentially improve our understanding of initiation of drug use and relapse and help develop innovative technology-based interventions to improve treatment and continuing care services.

Treatment of adults with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a clinically important neuropsychiatric developmental disorder that affects children, adolescents, and adults. The disorder is characterized by core symptoms of inattention, hyperactivity, distractibility, impulsivity, and impaired executive functioning. It is estimated that 2% to 5% of the adult population in the United States has ADHD. Adults with ADHD are at an increased risk for experiencing comorbid psychiatric disorders, including mood disorders, anxiety disorders, and substance use disorders. The authors provide a brief clinical overview of ADHD and the treatment of adults with this disorder.

Assessment of ADHD documentation from candidates requesting Americans With Disabilities Act (ADA) accommodations for the National Board of Osteopathic Medical Examiners COMLEX exam

PURPOSE

Every year increasing numbers of candidates request special accommodations for high-stakes medical licensing examinations, due to ADHD, on the basis of the Americans with Disabilities Act (ADA). This poses significant challenges for both the applicant and the medical boards and has significant financial, legal, and ethical implications. The purpose of this survey is to review all applications requesting ADA accommodations, on the basis of ADHD, submitted to the National Board of Osteopathic Medical Examiners (NBOME) COMLEX exam.

METHOD

The authors review all 50 requests for special accommodations, on the basis of ADHD, submitted to the NBOME between 2005 and 2007. All requests are reviewed by the investigators independently and then cross-checked to determine interrater reliability.

RESULTS

Of all applicants, only 14% (7/50) provide sufficient documentation to support a diagnosis of ADHD. Interrater reliability is high.

CONCLUSIONS

The majority of applicants who request special testing accommodations on the basis of ADHD do not provide adequate documentation to the medical boards to support the diagnosis.

Beta-lactam antibiotic reduces morphine analgesic tolerance in rats through GLT-1 transporter activation

Glutamate transporter subtype 1 (GLT-1) activation is a promising - and understudied - approach for managing aspects of morphine tolerance caused by increased glutamatergic transmission. Identification of beta-lactam antibiotics as pharmaceuticals which activate GLT-1 transporters prompted us to hypothesize that repeated beta-lactam antibiotic (ceftriaxone) administration blocks development of tolerance to morphine antinociception through GLT-1 activation. Here, we injected rats with morphine (10mg/kg, s.c.) twice daily for 7 days to induce tolerance and used the hot-plate assay to determine antinociception on days 1, 4 and 7 of repeated morphine administration. Ceftriaxone and a selective GLT-1 transporter inhibitor dihydrokainate (DHK) were co-administered with morphine to determine if GLT-1 activation mediated the ceftriaxone effect. Tolerance was present on days 4 and 7 of repeated morphine administration. Ceftriaxone (50, 100 or 200mg/kg, i.p.) administration dose-dependently blocked development of morphine tolerance. DHK (10mg/kg, s.c.), administered 15 min before each morphine injection, prevented inhibition of morphine tolerance by ceftriaxone (200mg/kg, i.p.). These results identify an interaction between ceftriaxone and morphine in opioid-tolerant rats and suggest beta-lactam antibiotics preserve analgesic efficacy during chronic morphine exposure.

The influence of neighborhood environment on treatment continuity and rehospitalization in dually diagnosed patients discharged from acute inpatient care

OBJECTIVE

Environmental contingencies inherent in neighborhoods and communities have been shown to affect individual behavior. The authors analyzed neighborhood and individual factors predicting initial outpatient treatment attendance and rehospitalization within 1 year among patients who were dually diagnosed with at least one mental disorder and a substance use disorder and discharged from an acute psychiatric inpatient care unit.

METHOD

Stepwise-forward logistic regression modeling and a geographic information system were utilized to assess data extracted from the medical records of 380 patients who, upon hospital admission, had one or more mental health disorders and a positive urine drug screen for prototypical illicit drugs. Geographic data on patients' neighborhood environment were obtained from public sources. Outcome variables were whether a patient attended the first outpatient treatment appointment within 30 days of hospital discharge and whether a patient was readmitted to the inpatient unit within 1 year of discharge. Predictor variables were features relating to individual-level patient characteristics and features associated with neighborhood environment.

RESULTS

Factors that decreased the likelihood of attending the initial outpatient treatment were returning home following hospitalization (versus returning to an institutional setting), residing in an area with a high vacant housing rate, residing in an area far from an Alcoholics Anonymous meeting location, having the chief complaint of bizarre behavior (i.e., grossly inappropriate behavior), and having a urine drug screen positive for heroin. The likelihood of being rehospitalized within 1 year was greater for Hispanic patients, patients who had at least one prior hospital admission, and patients who lived in close proximity to a Narcotics Anonymous meeting location. Patients living in areas with higher educational attainment had a reduced likelihood of rehospitalization.

CONCLUSIONS

A more explicit focus on the neighborhood and community context represents an important area in psychiatry, in terms of both research and clinical practice, which can potentially enhance long-term care and treatment planning for psychiatric patients. Future research is needed to better understand the influence of the neighborhood environment to help predict important clinical outcomes.

Doping in sports

Regardless of one's stance on the topic, drugs are an important issue in sports. Sports pages in newspapers around the globe routinely report on athletes at every level ofcompetition using performance enhancing substances to gain an unfair advantage over their competitors. The level of sophistication in beating drug testing, and developing "next-generation" agents continues to raise. The relative paucity of well designed research has been an additional factor impeding attempts to adequately address the problem. Very limited funds are currently available to conduct the necessary research. Without credible data, athletes are more vulnerable to the claims made by those benefiting from the sales of these compounds. Many younger fans and those dreaming of a similar future admire highly successful professional athletes. A strong, consistent statement admonishing drug use is needed. Actions speak louder than words. Every time a successful athlete is caught using PE drugs, every effort to diminish drug use is negatively impacted. The "win at all cost" and "second place is the first loser" mentality needs to be continually challenged by words and actions in youth sports at every level of competition. Finally, the war on drugs in sports needs to be a coordinated, well organized international undertaking as sports play an important role in virtually every culture. If we are to maintain the integrity of competition and protect the health of the athletes, we must dramatically increase our efforts to eliminate performance enhancing drugs as an acceptable option for any athlete. Sports science professionals and sports psychiatrists need to work with coaches, trainers, athletes, and national governing bodies to educating athletes on the effects of performance enhancing drug use. To achieve this important goal everyone involved in sports needs to be knowledgeable on the negative impact this has on all aspects of organized sports. It is a difficult challenge, but one that must be addressed.

Trichotillomania and trichobezoar: a clinical practice insight with report of illustrative case

Untreated trichophagia secondary to trichotillomania is a potentially life-threatening condition. Taking a thorough family and social history, most notably with the aid of a genogram or family tree, can aid in including this disorder in the differential diagnosis. This case presentation describes a unique occurrence of untreated trichotillomania in a female adolescent that led to formation of a trichobezoar requiring emergent surgical intervention and follow-up psychiatric treatment. This case highlights osteopathic medicine's fundamental concept of treating the whole person rather than just symptoms by considering factors such as genetic influences in understanding disease.

Schild (apparent pA2) analysis of a κ-opioid antagonist in Planaria

Previous investigators have provided radioimmunological and immunocytochemical evidence for an enkephalinergic (opioid) system in Planaria and described naloxone-sensitive qualitative behavioral responses to kappa-opioid receptor agonists. We report the application of Schild-analysis to the antagonism of a selective kappa agonist (U-50,488H) by a selective kappa antagonist (nor-BNI) in a quantitative in vivo endpoint. The results provide further evidence of a kappa-opioid-like receptor in planarians.

A nitric oxide synthase inhibitor (L-NAME) attenuates abstinence-induced withdrawal from both cocaine and a cannabinoid agonist (WIN 55212-2) in Planaria

We previously reported that planarians (Dugesia dorotocephala) that have been exposed to cocaine for 1 h undergo abstinence-induced withdrawal when placed into cocaine-free, but not cocaine-containing, water. We now report that planarians also display dose-related abstinence-induced withdrawal following exposure to the synthetic cannabinoid agonist WIN 55212-2, but not its inactive enantiomer (WIN 55212-3). The withdrawal from WIN 55212-2 was manifested as a significant (P < 0.05) decrease in the rate of planarian spontaneous locomotor activity over a 5-min observation period, using a recently designed metric (pLMV). We also report that withdrawal from cocaine (80 microM) or WIN 55212-2 (10 microM) was attenuated by the selective inhibitor of nitric oxide synthesis L-NAME (L-nitro-arginine methyl ester), which had no effect of its own on pLMV. These results suggest a common NO-dependent pathway of withdrawal from cocaine and WIN 55212-2 in Planaria.

Overdoses and ingestions of second-generation antipsychotics in children and adolescents

OBJECTIVE

We reviewed the available published data on intentional or unintentional secondgeneration antipsychotic overdoses in children and adolescents. The prescribing of secondgeneration antipsychotics has continued to increase over the past decade for children, adolescents, and adults. The authors reviewed the existing literature to determine the circumstances, presenting problems, treatment, and outcomes of youths who were exposed to nontherapeutic doses of these medications.

METHODS

A systematic English-language Medline search of all reports (1989-2005) and a review of the bibliographies of all articles obtained was done to identify papers reporting an overdose or ingestion of a second-generation antipsychotic. Data were reviewed on clozapine, risperidone, olanzapine, ziprasidone, quetiapine, and aripiprazole. The annual reports of the American Association of Poison Control Centers National Data Collection System were reviewed from 1990 to 2003, the most recent report currently available. All fatalities in children and youths under 18 years of age were included.

RESULTS

The literature review identified 40 reports that included 63 patients, ranging in age from 1 day to 17 years of age. The clinical presentations included drowsiness, lethargy, agitation, irritability, combativeness, and tachycardia. There were 11 fatalities in the cases reviewed, 1 from clozapine overdose, 3 from risperidone overdose, 2 from olanzapine overdose, and 5 from quetiapine overdose. All other cases reported no significant sequelae and resolved without any reported clinical consequences. Duration of overdose symptoms ranged from 24 hours to 7 days. One case of clozapine intoxication showed resolution of symptoms in 6 hours and, in another case of olanzapine overdose, symptoms resolved in 13 days. The most frequently employed treatments included intubation, gastric lavage, activated charcoal, intravenous fluids, artificial respiration, and restraints or sedatives.

CONCLUSIONS

There is a need for future case reports to include serum medication level, weight of patient, coingestants, the health of the patient at baseline, relevant laboratory and toxicology studies and a standardized scale to rate the level of consciousness, such as the Glasgow Coma Scale. The existing pharmacovigilance data reports indicate these medications are relatively safe when taken in overdose, particularly when coingestants are not involved.

Pronounced hypothermic synergy between systemic baclofen and NOS inhibitor

Baclofen was administered to rats systemically (intraperitoneal, i.p.) by itself or with L-NAME. Baclofen (1-7.5 mg/kg, i.p.) evoked dose-dependent hypothermia. L-NAME (50 mg/kg, i.p.) was ineffective. For combined administration, L-NAME increased the relative potency of baclofen (F=10.77, p<0.05), indicating multiplicative interaction and synergism. The present data reveal a surprising and significant interaction between nitric oxide synthase (NOS) and baclofen-induced hypothermia.

Case histories for understanding depression in primary care

The chief complaint of depressed patients in a primary care setting is often not their dysphoric mood. Physical complaints are frequently the presenting symptom. Primary care physicians should include a depressive disorder in the differential diagnosis of patients complaining of multiple somatic symptoms, increase in alcohol or drug use, sleep and sexual dysfunction, or reports of anxiety. In the case of acute onset of depression, the physician should first rule out underlying medical illness or medication side effects as the etiology of the symptoms.

Treating patients in primary care: the impact of mood, behavior, and thought disturbances

Patients with symptoms of mood, behavior, and thought disturbances are regularly treated in the primary care setting. More often than not, the disorders associated with these symptoms are overlooked or misdiagnosed by physicians, in part because these patients present symptomatic complaints that are seemingly unrelated to the underlying disorder. Recognition of comorbid psychiatric symptoms allows physicians to treat the whole person more effectively. Furthermore, patients and their caregivers benefit greatly from the early intervention and treatment that is frequently provided in the primary care setting. With the appropriate training so that they may readily recognize these symptoms, osteopathic physicians can help prevent the further progression of--or potential unfavorable outcomes from--otherwise untreated or inadequately treated illnesses.

Olanzapine overdose: a pediatric case report

This paper reports a case of an olanzapine overdose in a 12-year-old boy. An opioid-like presentation was noted. Despite a high serum level of olanzapine, the patient made a complete recovery and showed no sequelae at follow-up.

Sigma sites mediate DTG-evoked hypothermia in rats

1,3,-Di-o-tolylguanidine (DTG), a sigma agonist, produces hypothermia in rats, but the inability of purported sigma antagonists to block the hypothermia suggests that sites other than sigma may mediate the effect. Recently, N-[2-(3,4-dichlorophenyl) ethyl]-N-methyl-2-(dimethylamino) ethylamine (BD 1047) has been identified as a functional sigma antagonist in vivo because of its high selectivity for sigma sites and its ability to block DTG-induced dystonia and cocaine-evoked behaviors. Therefore, the present study investigated the effect of BD 1047 on DTG-evoked hypothermia. DTG (1, 10, 20 and 30 mg/kg sc) induced dose-dependent hypothermia. The onset of DTG-induced hypothermia was rapid, with a reduction in body temperature observed 15 min postinjection. To determine whether sigma sites mediated DTG-induced hypothermia, BD 1047 was injected 30 min prior to DTG. BD 1047 (1, 5, 7.5 and 10 mg/kg sc) attenuated the hypothermia in a dose-dependent fashion, thus revealing a sigma site mechanism. The injection of BD 1047 alone did not alter body temperature, suggesting that endogenous sigma systems do not play a tonic role in thermoregulation. The present experiments demonstrate for the first time that a selective sigma antagonist attenuates sigma agonist-induced hypothermia. Moreover, these data provide further evidence that BD 1047 is an effective antagonist for characterizing sigma-mediated effects in vivo.

Family functioning and peer affiliation in children of fathers with antisocial personality disorder and substance dependence: associations with problem behaviors

OBJECTIVE

Family functioning and peer influences are theoretically linked to child psychopathology. This study quantified the functional status of families with fathers with substance dependence with or without comorbid antisocial personality disorder and evaluated the peer environments of preadolescent offspring. The authors examined associations between the child's psychopathology, paternal substance dependence/antisocial personality disorder status, and measures of family and peer environments.

METHOD

Families with the presence or absence of paternal substance dependence were subdivided into those with and without paternal antisocial personality disorder. Grouped families were contrasted on measures of family functioning, the child's peer affiliation, and the child's problem behaviors. Regression analysis determined the influence of these factors on the child's psychopathology.

RESULTS

Families with paternal substance dependence functioned worse than normal comparison families. However, families with paternal substance dependence and antisocial personality disorder (N=34) did not differ markedly from those with substance dependence without antisocial personality disorder (N=84). The children of fathers with both substance dependence and antisocial personality disorder had greater affiliation with deviant peers than those with substance dependence without antisocial personality disorder and comparison families (N=104).

CONCLUSIONS

Children of fathers with substance dependence and antisocial personality disorder demonstrated higher externalizing and internalizing psychopathology than those with substance dependence but not antisocial personality disorder and those without either condition. Paternal substance dependence/antisocial personality disorder status and the child's affiliation with deviant peers were most robustly associated with the child's psychopathology. Research is needed to develop interventions that effectively address parental risk and healthy peer relations.

Preadolescent children of substance-dependent fathers with antisocial personality disorder: psychiatric disorders and problem behaviors

We compared psychiatric disorders and problem behavior scores in pre-adolescent children of fathers with alcohol or other drug dependence and ASP (SD+/ASP+), children whose fathers had substance dependence without ASP (SD+/ASP-), and children whose fathers were without either disorder (SD-/ASP-). SD+/ASP+ children showed elevated rates of major depression, conduct disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, and separation anxiety disorder when compared to SD+/ASP- and SD-/ASP- children. SD+/ASP+ children had higher internalizing and externalizing problem behavior scores than the other two groups of children. The results suggest that SD+/ASP+ children are at significant risk for internalizing and externalizing psychopathology.

Cyclooxygenase-2 expression in the developing human kidney

Cyclooxygenase (COX) exists in two related but unique isoforms, COX-1 and COX-2, and is suggested to have specific functions in different segments of the nephron. COX-2 knockout mice develop fatal nephropathy, which implies that this isoform is important during nephrogenesis. The histologic changes seen in the COX-2 knockout mice are similar to those observed in the kidneys of human fetuses exposed to non-steroidal anti-inflammatory drugs (NSAIDs) in the third trimester of pregnancy. However, only minimal amounts of COX-2 mRNA or protein have been reported in the adult human kidney. We hypothesized that expression of COX-2 is significant in the fetal human kidney and that it is involved in the development of the nephron. To characterize the presence of COX-2 in the human fetal kidney, we used immunohistochemistry to evaluate its expression in 23 fetal kidneys ranging between 15 and 23 weeks of gestational age. Strong expression of COX-2 was localized primarily in the macula densa and the thick ascending limb of the loop of Henle, and in rare glomerular podocytes and vascular endothelial cells. There was a progressive decrease in COX-2 immunoreactivity from the most immature nephrons adjacent to the metanephric regions to the well-developed nephrons in the middle to inner cortex. In contrast to the adult human kidney, this temporal and spatial expression of COX-2 in the fetal kidney suggests that this enzyme may be involved in nephrogenesis, and its inhibition by NSAIDs during the third trimester may be responsible for fetal renal syndromes.

Expression of cyclooxygenase-2 in the macula densa of human kidney in hypertension, congestive heart failure, and diabetic nephropathy

Cyclooxygenase-2 (COX-2) is constitutively expressed in the macula densa of several laboratory animal species where it is considered to play a physiologic role in the regulation of basal renal function. Pertubations to normal homeostasis is shown to be associated with the upregulation of COX-2 in the macula densa of rats and dogs. In contrast, COX-2 has not been detected in the macula densa of normal adult human and non-human primate kidneys, suggesting a less prominent role of this isoform in normal renal function in these species. In this study, we characterized COX-2 expression in human kidneys collected from subjects with a clinical history indicative of compromised renal function associated with diabetic nephropathy (DN), hypertension, and congestive heart failure (CHF). COX-2 expression was evaluated by immunohistochemistry using isoform-specific antibodies and in situ hybridization. No COX-2 protein or mRNA was observed in the macula densa of normal kidneys (n= 11), whereas slight to moderate COX-2 expression was present in the macula densa of 7/15 subjects (46%) with DN, 5/11 (46%) subjects with hypertension, and 3/10 subjects (30%) with CHF. These results indicate that COX-2 is variably induced in the macula densa of the human kidney in compromised renal conditions and that COX-2-mediated prostaglandins may be involved in maintaining adequate renal functions in some patients with DN, hypertension, and CHF. This variability may be related to individual clinical status or synthesis of vasodilatory prostaglandins by cyclooxygenase-1 (COX-1).

Treatment of childhood-onset schizophrenia with olanzapine

This paper reports on a clinical observation of 15 hospitalized youths ages 6-13 years diagnosed with childhood-onset schizophrenia and acutely treated with olanzapine. Initial sedation was the most common side effect observed. Youngsters who had not had a previous trial on any psychotropic did better than those that had failed a previous medication trial. Age was inversely correlated with positive response to olanzapine. Patients who experienced initial sedation did best once the initial sedation wore off. The majority of patients in the study improved on olanzapine.

The use of computer-assisted image analysis in the evaluation of preclinical tumor efficacy models

Quantitation in histopathology generates numerical or rank-order data amenable to statistical analysis, but can be very labor-intensive. The advent and coupling of computerized image analysis systems and optimized immunostaining procedures has not only decreased the laborious aspect of counting, but has also improved reproducibility and reliability by overcoming inter- and intra-observer variation. Still, a certain degree of manual intervention is required and a good understanding of the underlying biology is mandatory for proper design of the sampling system. Here, we focus on subcutaneous tumor models to illustrate the use and benefits of computer-assisted image analysis in quantitative histopathology. In particular, we discuss the quantitation of biological parameters frequently assessed in biology and toxicology: cell proliferation, apoptotic and oncotic necrosis, and angiogenesis. For each of these parameters, specific sampling procedures and labeling techniques are discussed based on current molecular and cellular concepts.

Timing of hysterectomy surgery during the menstrual cycle--impact of menstrual cycle phase on rate of complications: preliminary study

To determine the relationship between the timing of a hysterectomy performed during the menstrual cycle phase and the postoperative complication rate in women who had undergone surgery for dysfunctional uterine bleeding, the authors examined the charts of 24 patients for the 3-month period immediately after the hysterectomy. Twelve of the women were in the follicular phase, and 12 were in the luteal phase at the time they had undergone the hysterectomy. Patients were classified by operative pathology report. No significant differences (P < or = 0.05) were found between the two groups with respect to age, weight, para status, pathology, preoperative and postoperative hemoglobin levels, operation time, blood loss, days before return to full functioning, days in hospital, and uterine morphology. Further prospective studies with longer follow-up time are needed to obtain more conclusive indications regarding the optimal timing of hysterectomy during the menstrual cycle.

Thrombosis triggered by severe arterial lesions is inhibited by oral administration of a glycoprotein IIb/IIIa antagonist

Platelet aggregation and thrombosis play an important role in the onset of acute coronary events. Regardless of the stimulus for activation, platelet thrombus formation is ultimately regulated through the IIb/IIIa receptor complex. The effects of oral administration of xemilofiban, a non-peptide mimetic of the RGDF sequence of the IIb/IIIa receptor complex, on thrombus formation were evaluated in a canine model. Xemilofiban significantly reduced platelet deposition on severely damaged arterial wall. Platelet deposition was reduced at both low (13 +/- 1 from 56 +/- 18 x 10(6) platelets cm-2; P < 0.05) and high (23 +/- 2 from 111 +/- 21 x 10(6) platelets cm-2; P < 0.01) shear rates. Platelet deposition was reduced to a monolayer as seen by electron microscopy (platelet-vessel wall interaction). Therefore, the availability of an orally active IIb/IIIa antagonist for chronic use may have significant value in preventing thrombus formation in those clinical situations associated with severe arterial injury, such as atherosclerotic plaque disruption.

Manganese-based superoxide dismutase mimetics inhibit neutrophil infiltration in vivo

In a previous study (Hardy et al. (1994) J. Biol. Chem. 269, 18535-18540), we observed that the manganese-based superoxide dismutase mimetic Mn(II)-dichloro(1,4,7,10,13-pentaazacyclopentadecane) (MnPAM) inhibited neutrophil-mediated cell injury in vitro. We have extended these studies with the low molecular weight superoxide dismutase mimic to evaluate the role of superoxide in neutrophil-mediated tissue injury in vivo. In a dose-dependent manner, MnPAM inhibited colonic tissue injury and neutrophil accumulation into the colonic tissue induced by the intracolonic instillation of dilute aqueous acetic acid in mice. Tissue injury was assessed by visual and histological analysis. Neutrophil infiltration was determined by tissue myeloperoxidase activity and confirmed by histological analysis. Two novel Mn(II) dichloro complexes of the carbon-substituted macrocycles 2-methyl-1,4,7,10,13-pentaazacyclopentadecane (MnMAM) and 2-(2-methylpropyl)-1,4,7,10,13-pentaazacyclopentadecane (MnBAM) effectively catalyzed the dismutation of superoxide with catalytic rate constants (kcat) of 3. 31 x 10(7) M-1 s-1 and 1.91 x 10(7) M-1 s-1, respectively, as determined by stopped-flow kinetic analysis at pH 8.1 and 21 degrees C. The superoxide dismutase mimetics MnMAM and MnBAM also attenuated dilute aqueous acetic acid-induced tissue injury and neutrophil infiltration into colonic tissue; however, two Mn(II) complexes that had little or no detectable SOD activity (kcat </= 0.1 x 10(7) M-1 s-1), specifically the Mn(II) dichloro complexes of 1,4,7,10,13-pentaazacyclohexadecane and 1,4,7,11,14-pentaazacycloheptadecane, failed to inhibit the colonic tissue injury or infiltration of neutrophils in mice treated intracolonically with dilute aqueous acetic acid. These results are consistent with a proinflammatory role for superoxide in the mediation of neutrophil infiltration in vivo.

Basal and stimulated gonadotropin levels in the perimenopause

OBJECTIVE

We investigated whether perimenopausal menstrual cycle irregularity is associated with increased gonadotropin immunoactivity, bioactivity, or the bioactivity/immunoactivity ratio at baseline and after short-term stimulation with gonadotropin-releasing hormone.

STUDY DESIGN

Subjects consisted of four groups: (1) young regular cycling women (< 35 years old), older women (> 35 years) with (2) regular or (3) irregular menstrual cycles, and (4) postmenopausal women. Gonadotropin-releasing hormone stimulation tests (100 micrograms intravenous gonadotropin-releasing hormone) were performed in the National Institute of Mental Health outpatient clinic during the follicular phase of the menstrual cycle or randomly in postmenopausal women.

RESULTS

Perimenopausal women had baseline follicle-stimulating hormone and luteinizing hormone levels and stimulated follicle-stimulating hormone levels (area under the curve) that were similar to those of postmenopausal women and significantly greater than those of control (younger and older) women. Postmenopausal women had significantly greater baseline levels of luteinizing hormone bioactivity than did the other three groups. The bioactivity/immunoactivity ratio in the postmenopausal women was significantly greater than those in the perimenopausal and older cycling women, which were similar. No change in the bioactivity/immunoactivity ratio was seen after gonadotropin-releasing hormone stimulation in any group.

CONCLUSIONS

Although the perimenopause is associated with increases in baseline and stimulated gonadotropin levels similar to those seen after the menopause, significantly increased baseline luteinizing hormone bioactivity and the bioactivity/immunoactivity ratio are seen only after the menopause.

Pathology of perbutylated-N-butyl-1-deoxynojiromycin (an alpha-glucosidase-1 inhibitor) in Sprague-Dawley rats

Perbutylated-N-butyl-1-deoxynojiromycin (p-N-butyl-DNJ, SC-49483), an alpha-glucosidase-1 inhibitor, is a candidate anti-HIV agent targeted against viral glycoprotein processing in host cell endoplasmic reticulum. The potential toxicity of this compound was evaluated in Sprague-Dawley rats after 4, 13, or 26 wk of oral administration at doses ranging from 300 to 3,670 mg/kg/day. In these studies, the target organs of p-N-butyl-DNJ effects were thyroid gland, salivary gland, stomach, and pancreas. The most prominent histologic change in these organs was the presence of clear or lightly eosinophilic vacuoles in the cytoplasm of thyroid follicular cells, gastric chief cells, salivary gland acinar cells, and exocrine pancreatic acinar cells. Ultrastructurally, these vacuoles were consistent with dilated rough endoplasmic reticulum, which sometimes contained homogeneously stained, moderately electron-dense material. The vacuoles in thyroid follicular cells contained pale eosinophilic colloidlike material consistent with accumulated thyroglobulin, as shown by immunohistochemical staining methods. The biological functions of these organs were not adversely affected as evidenced by the absence of clinical signs and the results of selected hormonal analyses. The morphologic changes were completely reversed after a 4-wk recovery period. The incidence and severity of histologic changes were decreased after 13 and 26 wk of treatment compared to 4 wk of treatment, indicating an attenuation of the host response or adaptation to the prolonged p-N-butyl-DNJ administration. We believe that morphologic changes in thyroid follicular cells, salivary gland acinar cells, pancreatic acinar cells, and gastric chief cells were the result of nonspecific inhibition of host alpha-glucosidase(s) by p-N-butyl-DNJ, causing clinically silent perturbation in host cell glycoprotein processing and/or glycoprotein transport.