A comparative study reveals a similar validity of telepsychiatry and face-to-face psychiatric assessment in emergency room setting

Introduction

Telepsychiatry (TP) can provide an alternative to traditional face-to-face (FTF) assessments. However, TP in the emergency room setting is much less prevalent, probably due to lack of solid evidence about its effectiveness and acceptability.

Objectives

To directly compare traditional FTF and TP modalities in the emergency room setting.

Methods

Psychiatric patients (n=38) presented to the emergency room went through traditional in-person and videoconference TP interviews in varying order. Both FTF and TP interviewers that examined the patients as well as a third psychiatrist, acting as an observer for both modalities, determined the diagnosis, disposition recommendation and indication for involuntary admission.

Results

Rater decisions had a high matching on disposition and indication for involuntary admission (Cohen’s Kappa (CK) of 0.84/0.81, 0.95/0.87 and 0.89/0.94 for FTF-TP, Observer-FTF and Observer-TP, respectively). Although identical diagnosis matching between the raters was relatively low, the partial diagnosis matching was high (CK of 0.52/0.81, 0.52/0.85 and 0.56/0.85 for FTF-TP, Observer-FTF and Observer-TP, respectively). Telepsychiatry assessments had comparable acceptability in items such as psychiatrists’ certainty and interviewers’ and patients’ satisfaction.

Conclusions

TP and FTF psychiatric assessments in the emergency room settings have similar validity and acceptability. Implementation of TP in emergency room settings might improve the mental health services’ quality and access especially for remote populations. TP is especially important during the COVID-19 pandemic to enable treatment for epidemiologically isolated patients and to protect the medical personnel.

Real-time evaluation of individual cow milk for higher cheese-milk quality with increased cheese yield

Cheese was produced in a series of experiments from milk separated in real time during milking by using the Afilab MCS milk classification service (Afikim, Israel), which is installed on the milk line in every stall and sorts milk in real time into 2 target tanks: the A tank for cheese production (CM) and the B tank for fluid milk products (FM). The cheese milk was prepared in varying ratios ranging from ~10:90 to ~90:10 CM:FM by using this system. Cheese was made with corrected protein-to-fat ratio and without it, as well as from milk stored at 4°C for 1, 2, 3, 4, and 8d before production. Cheese weight at 24h increased along the separation cutoff level with no difference in moisture, and dry matter increased. The data compiled allowed a theoretical calculation of cheese yield and comparing it to the original van Slyke equation. Whenever the value of Afi-Cf, which is the optical measure of curd firmness obtained by the Afilab instrument, was used, a better predicted level of cheese yield was obtained. In addition, 27 bulk milk tanks with milk separated at a 50:50 CM:FM ratio resulted in cheese with a significantly higher fat and protein, dry matter, and weight at 24h. Moreover, solids incorporated from the milk into the cheese were significantly higher in cheeses made of milk from A tanks. The influence of storage of milk up to 8d before cheese making was tested. Gross milk composition did not change and no differences were found in cheese moisture, but dry matter and protein incorporated in the cheese dropped significantly along the storage time. These findings confirm that milk stored for several days before processing is prone to physico-chemical deterioration processes, which result in loss of milk constituents to the whey and therefore reduced product yield. The study demonstrates that introducing the unknown parameters for calculating the predicted cheese yield, such as the empiric measured Afi-Cf properties, are more accurate and the increase in cheese yield is more than increasing just the protein level, the value that is being tested by the dairies, or even casein.

Abstract OT2-03-02: DI study: Decision impact of the NanoString® Technologies Prosigna™ in early breast cancers

Backgrounds: More than a decade of research, clinical studies, and peer reviewed publications support the value of molecular subtyping based on gene expression analyses to assess prognosis and treatment options for patients with early-stage breast cancer. Therefore, genomic assays are now being introduced to supplement the conventional diagnostic tools. Prosigna is a standardized test that measures the expression levels of 50 classifier genes in formalin-fixed, paraffin-embedded (FFPE) breast tumor tissue samples and provide a subtype classification based on the fundamental biology of individual patient's tumor (referred to as molecular subtyping), as well as a prognostic score (referred to as risk of recurrence (ROR) score) that predicts the probability of cancer recurrence over 10 years.

The primary objective of this study is to assess the extent to which Prosigna affects the medical oncologist's treatment recommendations regarding adjuvant chemotherapy and actual treatments received for patients with early-stage breast cancer. Changes will include hormonal therapy alone, hormonal therapy plus chemotherapy, and changes in types of chemotherapy if chemotherapy was recommended before and after the test. Secondary objectives will be to elicit information on investigators' confidence in the recommendations before and after the test, and by cancer recurrence risk groups, rate of chemotherapy related adverse events stratified by administration of chemotherapy, and patients' decisional conflict status, anxiety levels, and functional status before and after Prosigna results.

Multicentric prospective study. Prosigna will be performed on operative piece for all consecutively postmenopausal women matching the inclusion criteria and having signed an informed consent. Data on patient demographics, disease status, intended cancer-specific postoperative management before and after the test, tests results, investigators and patients' confidence in the treatment and in the test, will be recorded in the inclusion visit, after the tests results and 6 month post-assay.

Inclusion criteria: Postmenopausal patients with resected node-negative, estrogen-receptor-positive, HER2-negative (by the local laboratory) early-stage invasive breast cancer (T1-T2, N0, pN0 (i+), pN1 (micrometastatic), M0), able to give consent, eligible for treatment of breast cancer with adjuvant chemotherapy and with ECOG performance status of 0 or 1.

Statistical methods: The clinical and demographic characteristics of the study sample will be described using mean, median, standard deviation, and range for continuous/ordinal variables and frequency and proportion for categorical variables. Bivariate plots and crosstabs will be performed to inspect bivariate associations between variables. The proportion of patients for whom the physicians' choice of treatment changed from baseline to follow-up will be calculated along with the 95% confidence interval. The change in investigator confidence in treatment recommendations before and after Prosigna results were known will be analyzed by calculating the mean and 95% CI for the question regarding whether a physician is more confidence in treatment recommendation after ordering Prosigna.

47 patients have been included on 200 scheduled.

Citation Format: Lerebours F, Hequet D, Guinebretière J-M, Roulot A, Callens C, Gentien D, Penault-LLorca F, Zilberman S, Salmon R, Foa C, Berseneff H, Huchon C, Katz G, MacDonald M, Morel P, Bieche I, Dubot C, Rouzier R. DI study: Decision impact of the NanoString® Technologies Prosigna™ in early breast cancers. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-03-02.

'An ounce of prevention is worth a pound of cure': the case for and against GnRH-agonist for fertility preservation

The late effects of cancer treatment have recently gained a worldwide interest among reproductive endocrinologists, oncologists, and all health-care providers, and the protection against iatrogenic infertility caused by chemotherapy assumes a high priority. Here, we summarize the case for and against using GnRH-agonist for fertility preservation and minimizing chemotherapy-induced gonadotoxicity. The rationale and philosophy supporting its use is that preventing premature ovarian failure (POF) is preferable to treating it, following the dictum: 'an ounce of prevention is worth a pound of cure'. Despite many publications on this subject, there are many equivocal issues necessitating summary. Until now, 20 studies (15 retrospective and 5 randomized, controlled trials) have reported on 1837 patients treated with GnRH-a in parallel to chemotherapy, showing a significant decrease in POF rate in survivors versus 9 studies reporting on 593 patients, with results not supporting GnRH-a use. Patients treated with GnRH-a in parallel to chemotherapy preserved their cyclic ovarian function in 91% of cases when compared with 41% of controls, with a pregnancy rate of 19-71% in the treated patients. Furthermore, seven meta-analyses have concluded that GnRH-a are beneficial and may decrease the risk of POF in survivors. However, controversy still remains regarding the efficiency of GnRH-a in preserving fertility. Since not all the methods involving fertility preservation are unequivocally successful and safe, these young patients deserve to be informed of all the various modalities to minimize gonadal damage and preserve ovarian function and future fertility. Combining several methods for a specific patient may increase the odds for minimally invasive fertility preservation.

Direct MD Simulations of Terahertz Absorption and 2D Spectroscopy Applied to Explosive Crystals

A direct molecular dynamics simulation of the THz spectrum of a molecular crystal is presented. A time-dependent electric field is added to a molecular dynamics simulation of a crystal slab. The absorption spectrum is composed from the energy dissipated calculated from a series of applied pulses characterized by a carrier frequency. The spectrum of crystalline cyclotrimethylenetrinitramine (RDX) and triacetone triperoxide (TATP) were simulated with the ReaxFF force field. The proposed direct method avoids the linear response and harmonic approximations. A multidimensional extension of the spectroscopy is suggested and simulated based on the nonlinear response to a single polarized pulse of radiation in the perpendicular polarization direction.

Fixed-combination brinzolamide 1%/brimonidine 0.2% vs monotherapy with brinzolamide or brimonidine in patients with open-angle glaucoma or ocular hypertension: results of a pooled analysis of two phase 3 studies

Purpose

To describe pooled efficacy and safety data from two phase 3 studies comparing brinzolamide 1%/brimonidine 0.2% fixed combination (BBFC) with its component medications, brinzolamide and brimonidine, in patients with open-angle glaucoma or ocular hypertension.

Methods

Data were pooled from two nearly identical clinical trials comparing BBFC with its component medications, each given three times daily. The 3-month efficacy outcome was mean intraocular pressure (IOP) at 0800, 1000, 1500, and 1700 hours. Safety outcomes included adverse events (AEs), best-corrected visual acuity, examination of ocular structures, pachymetry, perimetry, and vital signs.

Results

A total of 1350 patients were enrolled and included in this analysis (BBFC, n=437; brinzolamide, n=458; brimonidine, n=455). Baseline mean IOP levels were similar among the three treatment groups. At 3 months, mean IOP of the BBFC group was significantly lower than that of either monotherapy group (P<0.0001) at all the four time points. A total of 272 patients (20.1%) experienced at least one treatment-related AE (BBFC, 24.6% brinzolamide, 18.7% brimonidine, 17.4%), the majority of which were ocular AEs. One serious AE, moderate intensity chest pain, was considered related to brinzolamide treatment and resulted in study discontinuation.

Conclusions

This analysis strengthens the conclusions drawn from the two individual phase 3 studies showing that, in patients with open-angle glaucoma or ocular hypertension, BBFC had significantly superior IOP-lowering activity compared with either brinzolamide or brimonidine alone and a safety profile consistent with that of its individual components.

Detection of a new yellow fever virus lineage within the South American genotype I in Brazil

Nucleotide sequences of two regions of the genomes of 11 yellow fever virus (YFV) samples isolated from monkeys or humans with symptomatic yellow fever (YF) in Brazil in 2000, 2004, and 2008 were determined with the objective of establishing the genotypes and studying the genetic variation. Results of the Bayesian phylogenetic analysis showed that sequences generated from strains from 2004 and 2008 formed a new subclade within the clade 1 of the South American genotype I. The new subgroup is here designated as 1E. Sequences of YFV strains recovered in 2000 belong to the subclade 1D, which comprises previously characterized YFV strains from Brazil. Molecular dating analyses suggested that the new subclade 1E started diversifying from 1D about 1975 and that the most recent 2004-2008 isolates arose about 1985.

[Climatic aspects in hantavirus transmission areas in São Paulo State, Brazil]

The objective of this study was to investigate the spatial distribution of reported hantavirus cases in São Paulo State, Brazil (n = 80), from 1993 to 2005 and identify local climatic patterns during this period. Kernel point estimation of density was used to show the highest concentrations in Ribeirão Preto, São Carlos, Franca, Tupi Paulista, and Greater São Paulo. Increase in the number of cases during this period suggests disease dissemination even when considering increased diagnostic capacity and higher sensitivity of the health services. There was a marked seasonal variation in hantavirus in the cerrado (savannah) areas; the common pattern is a higher incidence in drier months as compared to mean levels in the last 40 years. These coincide with periods of high rodent food source levels in grains, sugarcane, and other crops. Harvesting and storing grains increases human exposure to rodents. Climatic indicators together with ecological variables can be local transmission risk markers and should receive more attention in epidemiological monitoring and control of the disease.

NRP/B mutations impair Nrf2-dependent NQO1 induction in human primary brain tumors

Brain tumors are associated with genetic alterations of oncogenes and tumor suppressor genes. Accumulation of reactive oxygen species (ROS) in cells leads to oxidative stress-induced damage, resulting in tumorigenesis. Here, we showed that the nuclear matrix protein nuclear restricted protein in brain (NRP/B) was colocalized and interacted with NF-E2-related factor 2 (Nrf2). During oxidative stress response, NRP/B expression and its interaction with Nrf2 were upregulated in SH-SY5Y cells. Association of NRP/B with Nrf2 was crucial for NAD(P)H:quinone oxidoreductase 1 (NQO1) expression. NRP/B was localized predominantly in the nucleus of normal brain cells, whereas in primary brain tumors NRP/B was almost exclusively contained in the cytoplasm. In addition, unlike wild-type NRP/B, the expression of NRP/B mutants isolated from primary brain tumors was found in the cytoplasm, and these mutants failed to induce Nrf2-dependent NQO1 transcription. Thus, NRP/B mutations and their altered localization resulted in changes in NRP/B function and deregulation of Nrf2-dependent NQO1 activation in brain tumors. This study provides insights into the mechanism by which the NRP/B modulates Nrf2-dependent NQO1 induction in cellular protection against ROS in brain tumors.

Case report: successful use of hyperbaric oxygen therapy for a complete scalp degloving injury

We report a case of a complete scalp degloving injury in a 43-year-old previously healthy, tobacco-using female whose hair was caught in a tractor power take-off causing an instantaneous total scalping injury. Microsurgical replantation was started 4 hours after injury with the surgical procedure lasting 4 hours. Only the superficial temporal arteries were reanastomosed with no venous anastomosis possible. Hyperbaric oxygen (HBO2) treatment at 2.5 atmospheres absolute (ATA) for 90 minutes was administered immediately after surgery due to duskiness of the flap. Further HBO2 treatments were administered twice daily for seven days and then once daily for 30 days. Additionally, leech therapy was used for the first ten postoperative days. The patient's right auricle and most of the left auricle were completely lost. Despite the tenuous vascular inflow and initially absent venous drainage, at 3 month follow-up there was reepithelialization of her scalp except for an area of granulation tissue in the occipitoparietal area. At one year follow-up the area of granulation tissue was reduced, but there was no detectable hair growth or nerve function. We propose that HBO2 may facilitate tissue survival in scalp degloving injuries in the face of incomplete surgical revascularization.

Hantavirus pulmonary syndrome in the State of São Paulo, Brazil, 1993-1998

Between 1993 and 1998, 10 cases of clinical hantavirus infection were diagnosed in Brazil. Hantavirus-specific IgM, or positive immunohistochemical analysis for hantavirus antigen, or positive reverse transcription-polymerase chain reaction results for hantavirus RNA were used to confirm nine of these cases; eight were hantavirus pulmonary syndrome (HPS), and one was mild hantavirus disease. The remaining clinical case of hantavirus infection was fatal, and no tissue was available to confirm the diagnosis. During the first 7 months of 1998, five fatal HPS cases caused by a Sin Nombre-like virus were reported from three different regions in the State of São Paulo, Brazil: two in March (Presidente Prudente Region), two in May (Ribeirão Preto Region), and one in July (Itapecerica da Serra Region). Epidemiologic, ecologic, and serologic surveys were conducted among case contacts, area residents, and captured rodents in five locations within the State of São Paulo in June of 1998. Six (4.8%) of 125 case contacts and six (5.2%) of 116 area residents had IgG antibody to Sin Nombre virus (SNV) antigen. No case contacts had a history of HPS-compatible illness, and only one area resident reported a previous acute respiratory illness. A total of 403 rodents were captured during 9 nights of trapping (1969 trap nights). All 27 rodents that were found to be positive for IgG antibody to SNV antigen were captured in crop border and extensively deforested agricultural areas where four of the 1998 HPS case-patients had recently worked. The IgG antibody prevalence data for rodents suggest that Bolomys lasiurus and perhaps Akodon sp. are potential hantavirus reservoirs in this state of Brazil.

Is the pediatric ureter as efficient as the adult ureter in transporting fragments following extracorporeal shock wave lithotripsy for renal calculi larger than 10 mm.?

PURPOSE

We determined whether the thin ureter of the young child transports stone fragments after extracorporeal shockwave lithotripsy (ESWL) as efficiently as the adult ureter does. This determination was done by comparing the outcome after lithotripsy of renal stones greater than 10 mm. between young children and adults.

MATERIALS AND METHODS

Our study group consisted of 38 children 6 months to 6 years old (median 3 years) with renal stones greater than 10 mm. in diameter. This group was further divided into 3 subgroups according to the longest stone diameter on plain abdominal film. There were 21 children with a renal stone diameter of 10 to 15 mm. (subgroup 1), 8, 16 to 20 mm. (subgroup 2) and 9 greater than 20 mm. (subgroup 3). The control group consisted of 38 adults older than 20 years randomly selected from the local ESWL registry. Each adult was matched with a child regarding stone diameter and localization. The control group was similarly divided into subgroups 1a, 2a and 3a. ESWL was performed with the unmodified Dornier HM-3 lithotriptor (Dornier Medical Systems, Inc., Marietta, Georgia). The stone-free rate, complication rate, and need for tubes, including stent or nephrostomy, and greater than 1 ESWL session were compared.

RESULTS

The stone-free rate was 95% in the study and 78.9% in the control group (p = 0.086). Stone-free rates were 95%, 100% and 89% in subgroups 1, 2 and 3, and 95%, 65% and 56% in subgroups 1a, 2a and 3a, respectively. There were 10 children and 4 adults who underwent greater than 1 ESWL session (p = 0.14). Then there were 10 children and 6 adults who required a tube before ESWL (p = 0.04), and almost all of them were included in subgroups 3 and 3a. Early complications were rare in both the study and control groups. Late complications had included 2 cases of Steinstrasse in the control and none in the study group.

CONCLUSIONS

The stone-free rate after ESWL for large renal stones is higher in young children compared to adults with matching stone size. Renal stones greater than 20 mm. often require more than 1 ESWL session. The pediatric ureter is at least as efficient as the adult for transporting stone fragments after ESWL.

[Doctor Westerlund's letters to Augusta Jansson]

Dr Ernst Westerlund--in Sweden called the Enköping-doctor--had his practice in the town of Enköping. Dr. Westerlund was known to be an excellent diagnostician; he had a very good reputation in Sweden and even abroad. He had a very personal and individual relation with his patients and the article describes a correspondence between him and one of his patients, Miss Augusta Jansson and is based on 150 letters from 1879 to 1923.

Kleptomania: diagnosis and treatment options

Kleptomania--the inability to resist the impulse to steal objects, not for personal use or monetary gain--is currently classified in psychiatric nomenclature as an impulse control disorder. However, some of the principle features of the disorder, which include repetitive intrusion thoughts, inability to resist the compulsion to perform the thievery and the relief of tension following the act, suggest that kleptomania may constitute an obsessive-compulsive spectrum disorder. Kleptomania is commonly under-diagnosed and is often accompanied by other psychiatric conditions, most notably affective, anxiety and eating disorders, and alcohol and substance abuse. Individuals with the disorder are usually referred for treatment due to the comorbid psychiatric complaints rather than kleptomanic behaviour per se. Over the past century there has been a shift from psychotherapeutic to psychopharmacological interventions for kleptomania. Pharmacological management using selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) and other antidepressants, mood stabilisers and opioid receptor antagonists, as adjuvants to cognitive-behavioural therapy, has produced promising results.

Recognition of viral hemagglutinins by NKp44 but not by NKp30

Natural killer (NK) cells destroy virus-infected and tumor cells without prior antigen stimulation. The NK cell cytotoxicity is regulated in large part by the expression of NK cell receptors that are able to bind major histocompatibility complex (MHC) class I glycoproteins. NK cells also express lysis triggering receptors specific for non-MHC ligands, including NKp30, NKp44, NKp46 and CD16. However, the nature of their ligands, recognized on target cells, is undefined. We have recently shown that the NKp46 protein, but not the CD16 protein, recognizes the hemagglutinin (HA) of influenza virus (IV) and the hemagglutinin-neuraminidase (HN) of Sendai virus (SV), and that the recognition of HA from IV requires the sialylation of NKp46 oligosaccharides. We have also demonstrated that binding of NKp46 to HA of IV is required for lysis of cells expressing the corresponding glycoproteins by a substantial subset of NK clones. Here we show that NKp44, but not NKp30, can also recognize the HA of both IV and SV and that the recognition of IV HA requires the sialylation of the NKp44 receptor in a similar way to that of NKp46. SV infection of 721.221 cells expressing MHC class I proteinsresulted in the abrogation of the inhibition by NK clones expressing high levels of NKp44. In addition, the binding of NKp44 to HA improves the ability of some NK clones to lyse IV infected cells.

[Use of spatial analysis tools in the epidemiological surveillance of American visceral leishmaniasis, Araçatuba, São Paulo, Brazil, 1998-1999]

The control of American visceral leishmaniasis (AVL) is based on combating the vector and eliminating the domestic reservoir of the focus area - defined as 200 meters around human or canine cases. This paper discusses the use of spatial analysis techniques in the epidemiological surveillance of AVL in Araçatuba, São Paulo State, in order to propose a model for territorial epidemiological surveillance, reformulating current control strategies. The results showed that AVL transmission was not homogeneous; human cases were more frequent in areas with higher canine prevalence rates. Vector dispersion appeared to be restricted to a few houses, although it was not possible to model the vector density. In order to study the vector distribution and correlated covariates, a field study based on house sampling is being conducted. The results will aid the development of new spatial analysis tools and possibly redefine protocols and routines for the control of this endemic disease in urban areas.

Recognition of HLA-Cw4 but not HLA-Cw6 by the NK cell receptor killer cell Ig-like receptor two-domain short tail number 4

NK cells are cytotoxic to virus-infected and tumor cells that have lost surface expression of class I MHC proteins. Target cell expression of class I MHC proteins inhibits NK cytotoxicity through binding to inhibitory NK receptors. In contrast, a similar family of activating NK receptors, characterized by the presence of a charged residue in their transmembrane portion and a truncated cytoplasmic tail, augment lysis by NK cells when ligated by an appropriate class I MHC protein. However, the class I MHC specificity of many of these activating NK receptors is still unknown. Here, we show enhanced lysis of HLA-Cw4 but not HLA-Cw6-expressing cells, by a subset of NK clones. This subset may express killer cell Ig-like receptor two-domain short tail number 4 (KIR2DS4), as suggested by staining with various mAb. It is still possible, however, that these clones may express receptors other than KIR2DS4 that might recognize HLA-Cw4. Binding of KIR2DS4-Ig fusion protein to cells expressing HLA-Cw4 but not to those expressing HLA-Cw6 was also observed. The binding of KIR2DS4-Ig to HLA-Cw4 is weaker than that of killer cell Ig-like receptor two-domain long tail number 1 (KIR2DL1)-Ig fusion protein; however, such weak recognition is capable of inhibiting lysis by an NK transfectant expressing a chimeric molecule of KIR2DS4 fused to the transmembrane and cytoplasmic portion of KIR2DL1. Residue alpha14 is shown to be important in the KIR2DS4 binding to HLA-Cw4. Implications of the role of the activating NK receptors in immunosurveillance are discussed.

Extracorporeal shock wave lithotripsy is highly effective for ureteral calculi in children

PURPOSE

Treatment of ureteral calculi in the pediatric population represents a unique challenge. Extracorporeal shock wave lithotripsy (ESWL*) and ureteroscopy have been advocated for the treatment of such stones. We present our experience with ESWL monotherapy for ureteral stones in children in the last decade.

MATERIALS AND METHODS

Between 1989 and 1999 we treated 21 boys and 17 girls with a mean age of 8 years (range 8 months to 14 years) with ureteral stones at our institution. Records were reviewed and analyzed for presentation, metabolic and anatomical anomalies, stone size and location, outcome and complications. Average stone size was 9.5 x 6.5 mm. (range 3 to 32). Stones were in the upper ureter in 17 cases, mid ureter in 2 and lower ureter in 19. All patients underwent ESWL with a Dornier HM3 lithotriptor under general anesthesia. Nephrostomies were placed in an anuric infant with bilateral ureteral obstruction and in 2 patients with nonfunctioning kidneys (4 renal units). Ureteral catheters were used in 15 patients for better identification and localization of the stone during ESWL. The catheters were removed immediately postoperatively.

RESULTS

Of the patients 31 (81.5%) were free of stones after 1 session of ESWL, 5 (13.1%) after 2 and 1 after 3. One patient underwent ureteroscopy for residual fragments after 2 ESWL sessions. The stone-free rate following 1 ESWL session was 100% for ureteral calculi 10 mm. or smaller regardless of location. Of the 12 patients with stones larger than 10 mm. 8 (67%) were free of stones following 1 ESWL session. The overall success rate of ESWL was 97.3%. No child had postoperative urinary infection or ureteral obstruction.

CONCLUSIONS

ESWL is an efficient and safe modality for the treatment of pediatric ureteral stones.

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY IS HIGHLY EFFECTIVE FOR URETERAL CALCULI IN CHILDREN

PURPOSE

Treatment of ureteral calculi in the pediatric population represents a unique challenge. Extracorporeal shock wave lithotripsy (ESWL*) and ureteroscopy have been advocated for the treatment of such stones. We present our experience with ESWL monotherapy for ureteral stones in children in the last decade.

MATERIALS AND METHODS

Between 1989 and 1999 we treated 21 boys and 17 girls with a mean age of 8 years (range 8 months to 14 years) with ureteral stones at our institution. Records were reviewed and analyzed for presentation, metabolic and anatomical anomalies, stone size and location, outcome and complications. Average stone size was 9.5 x 6.5 mm. (range 3 to 32). Stones were in the upper ureter in 17 cases, mid ureter in 2 and lower ureter in 19. All patients underwent ESWL with a Dornier HM3 lithotriptor under general anesthesia. Nephrostomies were placed in an anuric infant with bilateral ureteral obstruction and in 2 patients with nonfunctioning kidneys (4 renal units). Ureteral catheters were used in 15 patients for better identification and localization of the stone during ESWL. The catheters were removed immediately postoperatively.

RESULTS

Of the patients 31 (81.5%) were free of stones after 1 session of ESWL, 5 (13.1%) after 2 and 1 after 3. One patient underwent ureteroscopy for residual fragments after 2 ESWL sessions. The stone-free rate following 1 ESWL session was 100% for ureteral calculi 10 mm. or smaller regardless of location. Of the 12 patients with stones larger than 10 mm. 8 (67%) were free of stones following 1 ESWL session. The overall success rate of ESWL was 97.3%. No child had postoperative urinary infection or ureteral obstruction.

CONCLUSIONS

ESWL is an efficient and safe modality for the treatment of pediatric ureteral stones.

Dynamics of charge transfer states on metal surfaces: the competition between reactivity and quenching

The dynamics of excited states of adsorbates on surfaces caused by charge transfer is studied. Both negative and positive charge transfer processes are possible. In particular we are interested in positive charge transfer from a metal surface to molecular or atomic oxygen adsorbed on the surface. Once the negatively charged oxygen on the surface loses an electron it becomes chemically activated. The ability of this species to react depends on the quenching time or back transfer. The analysis of these processes is based on a set of diabatic potential energy surfaces each representing a different charged oxygen species. The dynamics is followed by solving the multichannel time-dependent Schrödinger equation or Liouville von Neumann equation. Due to the nonadiabatic character of these reactions large isotope effects are predicted.

Psychiatric aspects of jet lag: review and hypothesis

Jet lag is a travel-induced circadian rhythm phenomenon that afflicts healthy individuals following long- distance flights through several time zones. The typical jet-lag manifestations - insomnia during local sleep time, day fatigue, reduced concentration, irritability, and exhaustion with mild depression - are attributed to transient desynchronization in the circadian rhythm until the internal biological clock is rephased to the new environmental conditions. There is strong evidence relating affective disorders with circadian rhythm abnormalities. Less convincing suggestions relate jet lag to psychosis. It can be hypothesized that in predisposed individuals jet lag may play a role in triggering exacerbation or even de novo affective disorders. Furthermore, we propose the possibility that psychosis and even schizophrenia can be elicited by jet lag. This outlook gains its support from case studies and some common underlying phase-advanced biological denominators involved in both jet lag sufferers and psychotic patients.

Use of a modified American Urological Association Symptom Score for the evaluation of the quality of life of patients with prostate cancer

OBJECTIVES

To present our experience with the clinical use of a modified American Urological Association Symptom Score (AUASS) and a quality-of-life (QOL) questionnaire in obtaining clinically available information and to investigate whether a relatively short questionnaire, administered in the clinic, can help in identifying symptoms and QOL issues associated with various types of definitive treatments (DTs) for prostate cancer (PCa) and its impact on patients' QOL.

METHODS

The AUASS was modified to contain questions on continence and was combined with a short QOL questionnaire. It was administered to control groups and all patients with PCa during their clinic visit. The responses were analyzed and correlated with the DT of PCa.

RESULTS

The questionnaire was administered 846 times to 375 patients with PCa and to 170 controls during clinic visits. We found that patients on watchful waiting had symptom scores and QOL responses similar to controls and that DT was associated with worse scores and a reduced QOL. DT with continence was associated with a better QOL than DT with incontinence. Incontinence of either urine or stool, among DT patients, had similar adverse impact on QOL, compared with continent DT patients.

CONCLUSIONS

The questionnaire, administered in a clinical setting, provides insight into the QOL and symptoms associated with interventions aimed at curing PCa. The use of such a questionnaire enhances the objective documentation of treatment outcomes of PCa and benefits the patients by increasing their opportunities to express their problems.

Risperidone in treating behavioural disturbances of Prader-Willi syndrome

OBJECTIVE

This paper reports the results of risperidone treatment in seven patients (six adults and one adolescent) diagnosed as suffering from Prader-Willi syndrome (PWS) accompanied by severe behavioural disturbances. Risperidone was chosen following the failure of these patients to respond to other acknowledged modes of treatment for the psychiatric manifestations of PWS.

METHOD

This was a prospective open-label study. Measures of Clinical Global Impression Scale (CGIS), Retrospective Overt Aggression Scale (ROAS), Aggression Score (AS) and weight were obtained during two baseline visits and again following 37 weeks of treatment with risperidone.

RESULTS

Low dosages (1-3 mg/day; 1.6 mg/day on average) of risperidone brought about notable clinical improvement with no apparent adverse side effects. All measures evaluated--general behaviour, CGIS, OAS and weight--reacted favourably to the treatment protocol.

CONCLUSION

The preliminary results presented here suggest that risperidone is useful in treating PWS due to its positive effect on the disruptive behavioural symptoms that accompany it.

Pure follicle-stimulating hormone as an adjuvant therapy for selected cases in male infertility during in-vitro fertilization is beneficial

OBJECTIVES

Since research has demonstrated the possibility of hormonal therapy for male infertility, we conducted a study to analyze the efficacy of pure follicle-stimulating hormone (pFSH) treatment in patients with idiopathic, severe oligoteratoastheno-spermia (OTA) syndrome, or failed fertilization before referral to an intracytoplasmic sperm injection (ICSI) in an in-vitro fertilization (IVF) program.

STUDY DESIGN

A retrospective, clinical study was carried out on 178 men with OTA syndrome. Group I comprised 76 patients selected for treatment with pFSH. Group II comprised 102 men who served as the controls. Pure FSH was administered intramuscularly to the patients in group I. Upon cessation of therapy, an IVF treatment cycle was carried out.

RESULTS

After treatment with FSH, sperm motility was the only parameter which significantly improved in Group I (34% vs. 23%, and 15% vs. 24% in the subgroups of Group 1, respectively; P<0.05). In-vitro fertilization pregnancy rates were similar in both groups. The highest spontaneous pregnancy rates were achieved in FSH-treated, severe OTA patients.

CONCLUSIONS

Patients with severe male factor infertility may benefit from pFSH in terms of sperm motility, fertilization by IVF and spontaneous pregnancy rates. Selection criteria for FSH treatment are proposed.

Olanzapine and sulpiride: a preliminary study of combination/augmentation in patients with treatment-resistant schizophrenia

Coadministration of olanzapine, an atypical neuroleptic, with sulpiride, a selective D2 antagonist, is suggested as an efficient strategy for treating patients with resistant unremitting schizophrenia. The psychopharmacologic rationale that may account for the enhanced clinical efficacy of combining sulpiride with olanzapine and vice versa is the difference in affinity of the two drugs to brain receptors. Olanzapine affinity is related more to serotonin 5-HT2 than to dopamine-2, whereas sulpiride is considered a selective D2 blocker. The adjunction of a selective D2 antagonist to olanzapine may act as the olanzapine's augmentor by enhancing D2 blockage. This mode of treatment was introduced to six patients with chronic schizophrenia who showed noteworthy and rapid clinical improvement, supported by a decrease in their scores on the Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale. No bothersome side effects were noticed. This clinical approach is in accordance with the findings of previous reports assessing the efficacy of the combined treatment of clozapine and sulpiride. The grounds for this treatment regimen using olanzapine rather than clozapine are discussed, calling for further studies to affirm the hypothesis and clinical results.

[Drug abuse among patients requiring psychiatric hospitalization]

We assessed the incidence of drug abuse among patients requiring psychiatric hospitalization, and characterized the population at risk. The data on drug abuse were obtained from self-reports and urine tests in 103 patients, aged 18-65, hospitalized in the Kfar Shaul Psychiatric Hospital (autumn 1998). There was close correspondence between the self-reports and the results obtained from urine tests. 1/3 admitted to having used illegal drugs and signs of drug abuse were found in about 1/4 of the urine tests. The most prevalent drugs were cannabis products (hashish and/or marijuana) and in 15 patients opiates. Drug users were younger than non-users. With regard to psychiatric symptomatology, fewer negative symptoms were recorded among cannabis abusers with schizophrenia, compared to schizophrenic patients with no history, past or present, of cannabis abuse. The present findings confirm the clinical impression that there has been an increase in drug abuse among mental patients, parallel to that found in society at large. Confirmatory surveys are necessary. Our findings clearly suggest that a change in attitude has occurred in Israel to what has been considered a marginal problem. Hospitalized mentally-ill patients, the younger in particular, should be considered at risk for drug abuse.

[Jet lag causing or exacerbating psychiatric disorders]

Desynchronization of circadian rhythmicity resulting from rapid travel through at least 4 time zones leads to symptoms of jet lag syndrome. The most commonly experienced symptoms in normal individuals are sleep disorders, difficulties with concentrating, irritability, mild depression, fatigue, and gastrointestinal disturbances. There is strong evidence relating affective disorders to circadian rhythm abnormalities, such as occur in jet lag. Less convincing suggestions relate jet lag to psychosis. We presume, relying on the literature and our accumulated experience, that in predisposed individuals jet lag may play a role in triggering exacerbation of, or de novo affective disorders, as well as, though less convincing, schizophreniform psychosis or even schizophrenia. An illustrative case vignette exemplifies the possible relationship between jet lag following eastbound flight and psychotic manifestations.

Clozapine and risperidone: combination/augmentation treatment of refractory schizophrenia: a preliminary observation

OBJECTIVE

Clozapine and risperidone were the first two antipsychotic drugs of a new class of agents for the pharmacotherapy of schizophrenia. It has been suggested that refractory schizophrenic patients who fail to respond to neither clozapine nor risperidone may respond to a combination/augmentation strategy of both medicaments.

METHOD

Three cases of individuals with unremittent schizophrenia treated via this combination are presented. Response was evaluated by clinical follow-up and PANSS rating scale.

RESULTS

Good clinical results with no noticeable adverse side effects, ascertained by a reduction from baseline scores of the Positive and Negative Syndrome Scale (PANSS) were obtained in all three patients.

CONCLUSION

The findings from this pilot study suggest this combination as a possible therapeutic approach for treating resistant schizophrenic patients.

Jerusalem syndrome

BACKGROUND

Jerusalem's psychiatrists expect to encounter, as the millennium approaches, an ever-increasing number of tourists who, upon arriving in Jerusalem, may suffer psychotic decompensation.

AIMS

To describe the Jerusalem syndrome as a unique acute psychotic state.

METHOD

This analysis is based on accumulated clinical experience and phenomenological data consisting of cultural and religious perspectives.

RESULTS

Three main categories of the syndrome are identified and described, with special focus on the category pertaining to spontaneous manifestations, unconfounded by previous psychotic history or psychopathology.

CONCLUSIONS

The discrete form of the Jerusalem syndrome is related to religious excitement induced by proximity to the holy places of Jerusalem, and is indicated by seven characteristic sequential stages.

Ethanol-induced apoptosis in vitro

OBJECTIVES

The aim is to study the apoptotic process in a human hepatocyte model for ethanol (EtOH)-induced apoptosis.

DESIGN AND METHODS

Normal human primary hepatocytes (HPH) and Hep G2 cells were exposed to increasing EtOH. 6000 cells/ sample were analyzed by transmission electron microscopy.

RESULTS

Apoptotic cells were observed (mmol/L EtOH): 40: 6 +/-0.5%, 60:13 +/- 2% (p < 0.05), 80: 26 +/- 1% (p < 0.001) (vs. control). Two consecutive doses of 80 mmol/L for 24 h each additionally increased apoptosis 55 +/- 3% (p < 0.0001 vs. control and p < 0.001 vs. single dose). In response to this exposure, there is a stronger apoptotic activity in HPH when compared to Hep G2 (p < 0.05).

CONCLUSIONS

In vitro, EtOH-induced apoptosis is regulated by dose level and the frequency of exposure.

Withdrawal from clozapine: the "rebound phenomenon"

Clozapine is an "atypical" antipsychotic agent for treating previously resistant schizophrenic patients. Its main advantages over "typical" neuroleptics are low incidence of extrapyramidal side effects and its capacity to induce therapeutic response in previously treated refractory patients. However, withdrawal from clozapine has been observed to lead to "atypical" clinical characteristics or a "rebound phenomenon," manifested in two interwoven clinical forms: (1) psychotic exacerbation, and (2) cholinergic rebound. The underlying pathophysiological mechanism of this phenomenon is postulated to be a result of cholinergic supersensitivity. In this paper, the "rebound phenomenon" will be discussed and exemplified by three case histories in which abrupt cessation of clozapine led to serious deterioration and psychotic exacerbation, and one case in which gradual titration from the drug was employed in order to preempt this hazardous occurrence.

[Deaths caused by venomous snakes in the State of São Paulo: evaluation of 43 cases from 1988 to 1993]

The prognostic factors and the causes for obit occurrence in ophidian envenoming are yet not completely clear.

PURPOSE

To determine the prognostic factors and the most probable causes for obit occurrence in ophidian envenoming.

METHODS

In the State of São Paulo were notified 12,639 cases of accidents by venomous snakes from 1988 to 1993. There were 43 deaths (0.34%). The variables from the accident notification reports were compared with the promptuary notes and/or with the death records (in lethal cases).

RESULTS

The snake genus was classified in 11,297 accidents and in 41 from the lethal ones. Bothrops was responsible for 9,828 (87%) accidents and 28 (68.3%) deaths, Crotalus for 1,359 (12.0%) accidents and 13 deaths (31.7%) and Micrurus for 110 (1%) accidents and no death (p < 0.05). The information regarding to sex and age of the patients was available, respectively, in 12,620 and 12,527 accidents and in all lethal ones. There were 9,783 (77.5%) male patients in the accidents and 35 (81.4%) in the lethal cases (p > 0.05). Regarding to age, 15.9% of the patients and 41.8% of the ones who died were 50 years-old or more (p < 0.05). The most frequently bitten anatomic regions were: foot (42.2%), hand (20.6%), leg (17.6%), and ankle (13.1%) in the accidents, and foot (35.7%) and leg (35.7%) in the lethal cases (p < 0.05). Coagulation disorders occurred in 34 (91.9%) from 37 patients who died (those where this datum was available). The information above was not available in non lethal cases. The most common manifestations and complications implicated as possible death causes were: acute renal failure (34-79.1%), acute respiratory failure (28-65.1%), shock (18-41.9%), and sepsis (18-41.9%). Among all lethal cases but one without information, 29.4% of the patients died within the first two days after bite and 67.6% within the first 5 days. Acute respiratory failure was most common among the patients who died owing to crotalic envenoming, and sepsis was only seen in bothropic envenoming.

CONCLUSION

Most of the accidents and obits are caused by Bothrops; Crotalus envenoming, leg bites, and accidents in 50 year-old patients (or more) are frequently lethal; the most common complication in lethal cases is acute renal failure.