The impact of service user's suicide on mental health professionals

OBJECTIVES

Our principle objective was to examine the personal and professional impact of service user (SU) suicide on mental health professionals (MHPs). We also wished to explore putative demographic or clinical factors relating to SUs or MPHs that could influence the impact of SU suicide for MHPs and explore factors MHPs report as helpful in reducing distress following SU suicide.

METHODS

A mixed-method questionnaire with quantitative and thematic analysis was utilised.

RESULTS

Quantitative data indicated SU suicide was associated with personal and professional distress with sadness (79.5%), shock (74.5%) and surprise (68.7%) particularly evident with these phenomena lasting less than a year for more than 90% of MHPs. MHPs also reported guilt, reduced self-confidence and a fear of negative publicity. Thematic analysis indicated that some MHPs had greater expertise when addressing SU suicidal ideation and in supporting colleagues after experiencing a SU suicide. Only 17.7% of MHPs were offered formal support following SU suicide.

CONCLUSION

SU suicide impacts MHPs personally and professionally in both a positive and negative fashion. A culture and clear pathway of formal support for MHPs to ascertain the most appropriate individualised support dependent on the distress they experience following SU suicide would be optimal.

Seasonality of births in affective disorder in an Irish population

Seasonal variation in the births of patients with schizophrenia is a consistently replicated epidemiological finding. Few studies have investigated this phenomenon among patients with a diagnosis of affective disorder. The majority of season of birth studies have employed the chi square test for statistical analysis, a method that has been subject to some criticism. Using a Kolgomorov-Smirnov type statistic, the quarterly birth distribution of 6,646 patients with an ICD 9/10 diagnosis of affective disorder were compared to the general population. Only the births of those individuals with unipolar forms of affective disorder (n = 4,393) differed significantly from the general population, with significant excesses and deficits in the second quarter and fourth quarter respectively. These results were not altered by application of the displacement test. © 1998 Elsevier, Paris

Hodgkin lymphoma in a patient with chronic lymphocytic leukaemia--a rare presentation of Richter's transformation

Richter's transformation of chronic lymphocytic leukaemia (CLL) to high-grade B-cell Non-Hodgkin lymphoma occurs in < 5% of CLL cases. Transformation of CLL to Hodgkin Lymphoma is a much rarer event and here we describe a patient who developed Richter's transformation into a Hodgkin Lymphoma presenting as rapidly progressive hepatosplenomegaly.

Hypereosinophilic syndromes (HESs) variable clinical presentations and responses to treatment

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Background: Hypereosinophilic syndromes (HESs) refers to a heterogenous group of disorders characterised by marked blood eosinophilia (>1500/cu mm) and tissue eosinophilia (lasting for more than 6 months), in the absence of other eitiologies for eosinophilia, resulting in end organ damage. Eosinophilias may be reactive or due to a chronic myeloproliferative disorder (with evidence of clonal proliferation).Clonal eosinophilias are very often associated with the fusion gene FIP1L1-PDGFR alpha which causes the generation of a constitutively active Tyrosine Kinase. Treatment modalities for HES includes corticosteroids, chemotherapeutic agents, alpha- interferon, tyrosine kinase inhibitors (eg Imatinib mesylate) and the monoclonal anti-interleukin 5. Patients carrying FIP1L1-PDGFRalpha respond very well to Imatinib. Aim:Retrospective review of the variable response of 7 patients with HES (over a period of 6 months), to current treatment modalities. Methods: The 7 patients (6 Male, 1 Female; age range 37–80 yrs; mean age 56 yr) presented with eosinophilia in the range 2600–73,000 /cu mm.They were followed up for >6 months. A response to treatment was defined as Eosinophil count<1500 /cumm or Eosinophil count < 5% of the total leucocyte count .Four of the 7 patients received Imatinib as initial treatment. Two patient initially had steroids followed by Imatinib and 1 patient (aged 80 yr) was treated with Hydroxyurea initially. Results: Four of the 6 patients receiving Imatinib responded to it. Of the 2 patients not responding to Imatinib,1 responded partially to Hydroxyurea and the other did not respond to monotherapy with steroid or alpha-interferon (but eventually responded to a combination of the two). The patient who had initial treatment with Hydroxyurea responded well. Of the 7 patients 1 was positive for the FIP1L1-PDGFRalpha fusion gene,1 result was equivocal, 3 were negative and 2 were not tested (not available at the time). Of the 2 that were negative,1 responded to Imatinib. Conclusions: Response of HES patients to the various treatment modalities, is variable and often unpredictable.The FIP1L1-PDGFR alpha fusion gene is not often present;however other Tyrosine Kinases may be dysregulated and hence a trial of Imatinib is worth considering in most cases.

No significant financial relationships to disclose.

Variable clinical response of hypereosinophilic syndromes (HES) to current therapeutic options

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The term Hypereosinophilic syndrome (HES) refers to a heterogeneous group of disorders characterised by marked blood (>1500/cu mm) and tissue eosinophilia resulting in end organ damage.Several visceral complications like cardiomyopathies and cerebrovascular accidents are common. Treatment of HES includes corticosteroids,chemotherapeutic agents (hydroxyurea, cyclophosphamide, vincristine), interferon-alpha. Newer treatment modalities,including tyrosine kinase inhibitors (eg Imatinib) and monoclonal anti IL5 antibodies are now available. We report a case series of patients with HES which demonstrate the variable clinical response to above therapeutic options. Case 1: A 43 year old man who presented with a right lacunar infarct had a eosinophil count of 1200/cu mm. No cause was found. He also had Mitral valve endocarditis. Following initial treatment with Methylprednisolone, the eosinophil count came down to 3500/cu mm, but the eosinophilia persisted. He was given a trial of Imatinib. In 2 months time his eosinophilia resolved. However, he was negative for FILIPI-PDGFRa. Case 2: A 37 year old lady with history of Splenectomy (due to trauma) presented with a eosinophil count of 2660/cu mm. Result of the FILIPI-PDGFRa was equivocal. There was no response to Imatinib. A trial of Prednisolone (1 mg/Kg) was ineffective. She did not respond to Interferon-alpha. However when given a combination of Prednisolone (0.5 mg/kg) and Interferon-alfa, her counts were normal in a month. Case 3: A 63 year old man with history of Atrial Fibrillation had persistent eosinophilia (>1500/cu mm). His serum Tryptase was raised but he was negative for FILIPI-PDGFRa. A trial of Imatinib failed He responded partially to high dose of Hydroxyurea. Prednisolone, Interferon-alpha or a combination of both are future options for him. Case 4: A 80 year old man with background history of Alzheimer’s Disease was found to have persistent unexplained eosinophilia. He had no complains of joint symptoms but his ANF was positive in low titres. A bone marrow showed no evidence of lymphoma or a myeloproliferative disorder. Karyotype was normal. He was given a trial of Hydroxyurea to which he responded in two weeks. Thus, response of HES patients to treatment is variable often unpredictable.

No significant financial relationships to disclose.

Myelodysplastic patients with raised percentage of hypochromic red cells have evidence of functional iron deficiency

Raised percentage hypochromic red cells (%HRC) were detected at diagnosis in 10 of 34 consecutive patients with low-risk myelodysplastic syndrome (MDS) [refractory anemia (RA) (4/26) and RA with ring sideroblasts (6/8)], all of whom had normal or increased serum ferritin and bone marrow iron stores. Elevated %HRC has persisted in all 10 cases and subsequently developed in another RA patient who later had a complete remission of MDS with normalisation of %HRC after a respiratory tract infection. A strong positive correlation was found between %HRC and erythrocyte zinc protoporphyrin levels in 11 MDS patients tested (p=0.01), suggesting that functional iron deficiency contributes to ineffective erythropoiesis in cases of MDS with raised %HRC. Five of seven patients with elevated %HRC had satisfactory haemoglobin responses to a trial of human recombinant erythropoietin without iron supplementation.

Treatment of refractory fludarabine induced autoimmune haemolytic with the anti-cd20 monoclonal antibody rituximab

A patient with cold-type autoimmune haemolytic anaemia for 8 years developed progressive B cell chronic lymphocytic leukaemia (CLL). Despite the risk of fludarabine induced exacerbation of haemolysis, he was given aggressive anti-CLL therapy with six courses of FCR (fludarabine 25 mg/m2 D1-3, cyclophosphamide 250 mg/m2 D2-4 and rituximab 375 mg/m2 D1) every 4 weeks. This resulted in a marked acute increase in haemolysis shortly after completing each course of fludarabine. However, haemolysis had settled to its baseline level by the time of subsequent courses of FCR. FCR resulted in complete clinical remission of CLL but residual haemolysis persisted. The patient was then given four weekly infusions of single agent rituximab, resulting in ongoing remission of haemolysis. In this patient, rituximab appears to have controlled fludarabine induced exacerbation of autoimmune haemolysis. In addition, subsequent single agent rituximab therapy resulted in prolonged remission of cold-type autoimmune haemolytic anaemia. It remains to be seen if the addition of rituximab will allow other patients with a positive direct Coomb's test and/or autoimmune haemolysis to receive fludarabine containing chemotherapy without undue risk of life-threatening haemolytic anaemia.

CML clonal evolution with resistance to single agent imatinib therapy

We describe a 58-year-old male diagnosed with chronic myeloid leukaemia (CML) who failed to have a cytogenetic response to interferon-alpha and hydroxyurea. On subsequent therapy with imatinib mesylate he failed to have any cytogenetic response but also developed a complex clonal evolution with an additional Philadelphia (Ph) chromosome and trisomy 8 respectively in two Ph-positive subclones. The addition of cytosine arabinoside to imatinib resulted in reversion to single Ph-chromosome positivity with the disappearance of the previous additional clonal abnormalities. The case demonstrates the efficacy of combined treatment with imatinib and cytarabine in the management of CML resistant to single agent imatinib.

Autologous stem cell transplantation in myeloma: the St James's Hospital experience, 1997-2003

BACKGROUND

High-dose treatment with autologous stem cell transplantation (ASCT) has become the standard of care for patients with myeloma below the age of 65 years.

AIMS

We report an audit of 60 patients (median age: 52.5 years) who underwent ASCT in the National Bone Marrow Transplant centre in St James's Hospital in Dublin between 1997 and 2003 inclusive.

METHODS

Clinical and laboratory data were retrieved from patient medical records and hospital information management systems.

RESULTS

Thirty-six patients had IgG, 11 IgA, 1 IgD, 9 light chain and 3 non-secretory MM. Fifty-seven (95%) patients received anthracycline-corticosteroid combination chemotherapy prior to autografting. There was no transplant-related mortality (TRM). Complete (CR) and Partial Responses (PR) were seen in 16 (29.6%) and 29 (53.7%) of those evaluable (n = 54 (90%)). The actuarial Progression-Free (PFS) and Overall Survival (OS) rates at five years are 13% and 55% respectively.

CONCLUSION

Centre outcome is comparable to published international series and supports the use of ASCT in the treatment of this malignancy.

Chronic myeloid leukemia and acromegaly in POEMS syndrome

We describe an acromegalic patient who has developed both chronic myeloid leukemia (CML) and a plasma cell dyscrasia. However, as the patient also has neuropathy, hyperhydrosis and other endocrine disorders, he appears to have an atypical form of POEMS syndrome.

Dermatoglyphic fluctuating asymmetry and atypical handedness in schizophrenia

Atypical handedness and dermatoglyphic abnormalities are hypothesized to reflect a neurodevelopmental disturbance in schizophrenia. Developmental instability, indexed by dermatoglyphic fluctuating asymmetry (FA), reflects the degree to which an individual's ontogenetic program is maintained and provides a useful framework in which to consider atypical handedness in schizophrenia. Thirty patients diagnosed with schizophrenia were compared with 37 matched healthy controls on levels of dermatoglyphic FA, a demonstration task determining hand preference and a test of relative hand skill. Multivariate analyses established that patients demonstrated greater FA and more atypical hand skill compared with controls. In patients, but not in controls, there was a strong positive association between a measure of FA and a measure of atypical hand skill, suggesting that these markers of neurodevelopmental disturbance are related in schizophrenia. On a measure of hand preference, patients were more likely than controls to be classified as mixed handed than either right or left handed. Results from the present study support the conjecture of greater developmental instability in schizophrenia affecting neurodevelopmental processes, including those conferring manual dominance.

Low risk of central venous thrombosis with nontunnelled central venous catheters

142 noncuffed, nontunnelled, single lumen central venous catheters were inserted in 103 patients with haematological malignancy. Insertion related complications were minimal and no symptomatic catheter-related central venous thrombosis occurred. Nontunnelled central venous catheters are an excellent alternative to the more commonly used tunnelled devices in terms of convenience, cost-effectiveness and low incidence of side effects.

Microxine, a new cdc2 kinase inhibitor from the Australian marine sponge Microxina species

A new purine derivative microxine (1) was isolated from the Australian marine sponge Microxina sp. The compound was isolated via reversed-phase chromatography and its structure determined spectroscopically. Microxine was found to weakly inhibit cdc2 kinase activity with an IC(50) of 13 microM.

Paroxysmal cold haemoglobinuria caused by non-Hodgkin's lymphoma

Paroxysmal cold haemoglobinuria is an autoimmune haemolytic anaemia characterized by a biphasic polyclonal IgG autoantibody, the Donath-Landsteiner (D-L) antibody. Although classically described in association with chronic syphilis, it is most commonly seen after acute viral infections in children. We describe a case of high-grade B-cell non-Hodgkin's lymphoma which presented with paroxysmal cold haemoglobinuria. The lymphoma responded promptly to combination chemotherapy whilst, at the same time, the haemolytic process rapidly resolved. Subsequent investigations showed that the D-L antibody originated from the lymphoma cells.

Octa- and nonaprenylhydroquinone sulfates, inhibitors of alpha1,3-fucosyltransferase VII, from an Australian marine sponge Sarcotragus sp

Alpha1,3-fucosyltransferase (Fuc TVII) is a key enzyme in the biosynthesis of selectin ligands. We have isolated two inhibitors of Fuc TVII from a marine sponge Sarcotragus sp. They were characterized as octa- and nonaprenylhydroquinone sulfates on the basis of spectral data. These compounds inhibited Fuc-TVII with IC50 values of 3.9 and 2.4 microg/mL, respectively.

Adjunctive treatment of compartment syndrome with hyperbaric oxygen

Trauma-induced compartment syndrome and other acute traumatic peripheral ischemias have been effectively treated with hyperbaric oxygen therapy. We describe a case of compartment syndrome associated with an acute exertional injury. After surgical decompression, hyperbaric oxygen therapy reduced edema and improved tissue viability. The mechanisms of hyperbaric oxygen applicable to the pathophysiology of compartment syndrome are described. We believe that hyperbaric oxygen is a useful intervention in the management of compartment syndrome.

Audit of patients on oral anticoagulants with International normalized ratios of eight or above

We reviewed retrospectively the medical records of all patients (n = 77, mean age 74.2) on oral anticoagulants with an International normalized ratio (INR) of eight or above in a 12-month period in the Leicestershire District Health Authority (DHA). From a total of 55,625 INRs, 131 (0.24%) were > or = 8. A major cause of over-anticoagulation was unsatisfactory dose loading during in-hospital commencement of oral anticoagulation. The incidence of major bleeding was 12.9% of total episodes of INR > or = 8 with two haemorrhage-related fatalities. Therapy of major haemorrhage with fresh frozen plasma (FFP) and intravenous (i.v) vitamin K proved effective but was not given in a majority of such cases. In conclusion, improvements in initial dose loading of oral anticoagulation and in the management of major haemorrhage are required. Severely over-anticoagulated patients without obvious bleeding should nevertheless receive small dose vitamin K therapy to reduce the risk of haemorrhage related morbidity and mortality without compromising subsequent oral anti-coagulant control.

Lymphoma associated bone marrow necrosis with raised anticardiolipin antibody

A case of high grade B cell lymphoma presented with bone marrow necrosis, followed by development of extensive marrow fibrosis, the evolution of which was documented by serial magnetic resonance imaging and bone marrow trephine histology. A markedly raised anticardiolipin antibody titre at diagnosis suggests that lymphoma associated antiphospholipid syndrome may have contributed to the aetiology of the bone marrow necrosis.

Primary cardiac lymphoma: death from cardiac asystole after attaining second complete remission

A patient with primary high grade cardiac lymphoma, diagnosed by pericardial fluid cytology, achieved complete remission with chemotherapy. After a relapse 11 months later, a second complete remission was attained with radiotherapy and chemotherapy but the patient suffered a fatal cardiac asystole during intensification therapy. A review of the recent literature suggests that prognosis for this rare extra nodal lymphoma has markedly improved as a result of early diagnosis and prompt institution of aggressive antilymphoma therapy.

Interleukin-4 and tumour necrosis factor-alpha produce non isotype specific partial differentiation of peripheral blood B-cells in myeloma

In a previous study, culture of peripheral blood mononuclear cells (PBMC) from myeloma patients with interleukin(IL)-4 and tumour necrosis factor(TNF)-alpha resulted in the appearance of clonal plasma cells, thus suggesting the presence of circulating myeloma cell precursors in the peripheral blood. Using the same cytokine combination, we cultured PBMC and purified peripheral blood B-cells from myeloma patients. In nearly all cases, partial differentiation of B-cells occurred but, similarly to results for normal controls, both kappa and lambda light chain (L.C.) cytoplasmic positive lymphoid and lymphoplasmacytoid cells were detected rather than clonal plasma cells. These results suggest that IL-4 and TNF-alpha cause partial differentiation of residual normal polyclonal B-cells rather than of circulating myeloma cell precursors in the peripheral blood of myeloma patients.

Autoimmune haemolytic anaemia associated with ulcerative colitis

We describe only the second reported case of ulcerative colitis to develop autoimmune haemolytic anaemia following previous subtotal colectomy. After an unsatisfactory trial of corticosteroids and azathioprine, the haemolysis responded to splenectomy and removal of rectal stump and anal canal.

Successful use of topical retinoic acid in severe dry eye due to chronic graft-versus-host disease

Topical retinoic acid has proved to be of variable benefit in a number of dry eye disorders of disparate aetiology, in which squamous metaplasia with keratinization of ocular epithelium is present. Its exact role in patients with dry eye however remains in dispute. We describe a case of severe dry eye due to chronic graft-versus-host disease, which was refractory to conventional therapy but which responded remarkably to topical retinoic acid with reversal of conjunctival keratinization and marked resolution of symptoms.

Australian deliberations on access to its terrestrial and marine biodiversity

The predominantly developed country business principle that the natural resource is effectively free, or of very low monetary value, has been significantly challenged in recent years, not only through the recognition of the accelerated rate of depletion of native forest resources and of the space and food demands of increasing populations, but also through international conventions which deal with a wide range of topics from the rights of indigenous people to the Law of the Sea Convention. Australia, classified as a developed country, but located in a geographic region of many developing countries, has, in the past 25 years, demonstrated particular concern for the rights of the people of those countries, as well as for the rights of indigenous people of Australia. The practical international aspects were clearly exemplified in the time, from 1985, when the Australian Institute of Marine Science (AIMS) negotiated, within the National Cancer Institute (NCI) contract, that collections of biological samples in developing countries would be accompanied by an agreement to provide benefits arising from field work, and from any commercial product developments, to those countries. Australia, as a signatory to the Convention on Biological Diversity (Appendix I), continues to analyze the challenge presented by the need to freely exchange genetic resources of common value, e.g. food crops, while insuring an appropriate reward to developing and developed countries, should discoveries be made from their biological resources, which lead directly or indirectly, to high value commercial non-food products. The Prime Minister's Coordinating Committee on Science and Technology established a special working group to recommend on access to Australia's biodiversity. The report arising from the study, and other related issues, are discussed.