A controlled trial of home-based acute psychiatric services. I: Clinical and social outcome

While research has shown community-based psychiatric care to be as good as, or better than, hospital-based care, generalisation to clinical practice has been difficult. This prospective, randomised controlled study examined a community-based approach feasible within NHS conditions. Ninety-four patients were randomly allocated to experimental and 78 to control treatments and followed for one year. The groups were well matched apart from an excess of psychotic control patients. No differences in clinical or social functioning outcome were found. Both groups improved substantially on clinical measures in the first six weeks, with some slow consolidation thereafter. There were three suicides in the control group and one in the experimental group. Access to care was better in the experimental group (93% attended assessment) than in the control group (75% attended assessment).

Lack of effect of influenza vaccine on anticoagulation by acenocoumarol

OBJECTIVE

To analyze the effects of influenza vaccine on patients receiving chronic anticoagulant therapy with acenocoumarol.

DESIGN

A prospective trial.

SETTING

Hospital de la Santa Creu i Sant Pau, Barcelona.

PATIENTS

Forty-three patients who received acenocoumarol, had stable levels of International Normalized Ratio (INR), and did not need dosage modification for four months before entering the study.

INTERVENTION

A study of anticoagulation levels measured by INR at 7, 15, and 30 days from administration of the trivalent vaccine from the 91-92 campaign was conducted.

MAIN OUTCOME MEASURES

Comparison was made between basal values (day 0) and anticoagulation levels at 7, 15, and 30 days from vaccine administration by means of a repeated-measures ANOVA.

RESULTS

Nine patients (21 percent) had INR levels out of the therapeutic range during the study period. INR increased in three of these patients and decreased in six. There were no significant intraindividual changes in INR values during the time period analyzed (p = 0.125). No hemorrhagic or thrombotic manifestations occurred and no significant changes in renal or hepatic biochemistry were observed.

CONCLUSIONS

Influenza vaccine does not modify acenocoumarol activity in patients receiving long-term anticoagulant therapy.

[Pregnancy and thrombophilia in women with congenital deficit of antithrombin III, protein C, protein S or plasminogen: analysis of 39 cases]

BACKGROUND

Pregnancy, delivery and puerperium are situations which increment the risk of thromboembolic complications in women who are carriers of congenital heterozygotic deficits of type I antithrombin III (ATIII), protein C (PC) or protein S (PS). The aim of this study was to analyze the experience of the authors and propose therapeutic conduct in each case. Furthermore, the spontaneous losses of pregnancy related with these deficits were studied.

METHODS

Thirty-nine women, seventeen with ATIII deficit, fifteen with PC deficit and four with a deficit of PS and three with a plasminogen (Pg) deficit totalling 79 pregnancies and 51 thrombotic episodes sixteen of which were related with the pregnancy, delivery or puerperium were studied. The antigenic and functional activity of ATIII, PC, PS and Pg were determined.

RESULTS

The incidence of thrombosis for the ATIII deficit during pregnancy was 39%, which was greater, of statistical significance (p = 0.046), than the 15% observed during puerperium. In women with a deficit of PC, the incidence of thrombosis was 4.5% during pregnancy and 14% during puerperium with no significant difference between the two situations. The incidence of thrombosis during pregnancy and postpartum in the deficit of ATIII was significantly higher (p < 0.025) than that observed for the deficit of PC. For women with a deficit of PS and Pg the incidence of thrombosis was nul in pregnancy and puerperium.

CONCLUSIONS

Pregnancy and puerperium are situations which trigger thrombotic phenomena and increase the risk of the same in women with a deficit of antithrombin III and protein C and, to a lesser degree, the deficit of protein S or plasminogen. A strict control of these situations and individualized treatment is required according to the type of deficit, presence of previous thromboembolic history and anticoagulant history at the time of pregnancy. No increase in the risk of loss of pregnancy in any of the deficits studied was observed.

Use of 'original antigenic sin' theory to determine the serotypes of previous dengue infections

Determination of serotypes of dengue viruses involved in sequential infections is important since, according to a theory of the pathogenesis of dengue haemorrhagic fever, a particular serotype may be a risk factor. It has been reported in Asia that at least the serotypes involved in the first infections could be serologically identified by the plaque reduction neutralization test (PRNT) because the highest PRNT titres after the second infections corresponded to the serotypes in the first infections. We re-examined the application of this theory of 'original antigenic sin' in Puerto Rico to evaluate its utility in serodiagnosis. Our results showed that it could not be applied reliably because of discrepant results.

[Influence of chronic renal failure and of its treatment on serum erythropoietin]

BACKGROUND

In order to know the influence of dialysis treatment in erythropoietin production, serum erythropoietin (Ep) has been studied in patients with anemia due to chronic renal failure (CRF).

METHODS

Thirty six of them in hemodialysis (HD), 10 in continuous ambulatory peritoneal dialysis (CAPD) and 18 in predialysis stage (PD) and their results were compared to two control groups, including 72 healthy controls (HC) and the second one 89 iron deficiency anemia patients (ID).

RESULTS

Patients had lower Hb and Ep levels than the other groups. Although Ep was higher in CAPD and PD. Ep levels were similar to HC values, and lower than ID levels. It could be demonstrated any correlation between Hb and Ep in CRF patients, however a negative exponential correlation was demonstrated in ID patients between Hb and Ep (r = -0.83; p less than 0.00001). In summary, Ep is higher in CAPD and in PD than in HD, but the levels are lower than they should be expected.

CONCLUSIONS

These data confirm an Ep production failure in most of IRC patients and it seems likely that Ep treatment could be effective to treat the anemia of CRF.

[Pyknodysostosis: extreme cause of sleep apnea]

We describe a twentieth month old infant who had a pycnodysostosis syndrome. This malformation shows a loss of the normal mandible angle with generalized bone hyperdensification. The first produced and airway obstruction, with special relevance during sleeping hours. A polysomnography revealed an obstructive sleep apnea syndrome. The respiratory picture deteriorated with worsening of the airway obstruction, hypoxemia and finally pulmonary hypertension and cor pulmonale. A tracheostomy was performed, with resolution of the sleep apnea and pulmonary hypertension. The etiology, pathophysiologic consequences and surgical treatment of obstructive sleep apnea syndrome is reviewed.

[Markers of hypercoagulability during pregnancy: thrombin-antithrombin-III complexes and D dimer]

Pregnancy can be regarded as a secondary hyper-coagulability state. The development of thrombin-anti-thrombin complexes (TATC), D dimer and anti-thrombin III (AT III) was analysed in the present work on 33 pregnant women. A significant increase of the TATC records was found between the first and third trimesters and between the second and third trimesters (p = 0.005 and p = 0.02, respectively). The AT III values were within the normal range. The values of the D dimer increased progressively during pregnancy, but only the figures achieved in the third trimester were statistically significant with respect to the control group (p = 0.14). The increase of TATC and D dimer during pregnancy are considered as hypercoagulability.

Bicuculline-induced epileptogenesis in the human neocortex maintained in vitro

Intracellular and extracellular recordings were made from human neocortical slices of the temporal lobe maintained in vitro. The slices were treated with bicuculline methiodide to reduce synaptic inhibition mediated by tha gamma-aminobutyric acid A (GABAA) receptor. Spontaneously occurring epileptiform activity was never observed in over 60 slices examined. All epileptiform discharges were elicited by single-shock stimuli delivered in the underlying white matter or within the cortical layers. Intracellularly, the stimulus-induced epileptiform discharge resembled the paroxysmal depolarization shift (PDS). This potential was observed in neurons located between 200 and 2200 microns from the pia. It was characterized by a 100-1800 ms long depolarization which triggered burst firing of action potentials, and was at times followed by an afterdischarge. Simultaneous intracellular and extracellular recordings showed that each PDS was reflected by the synchronous discharge of a neuronal aggregate. The voltage behaviour of the PDS and its preceding EPSP was analyzed in cells that were injected with the lidocaine derivative QX-314. The amplitudes of the PDS depolarizing envelope measured at its peak and during its falling phase both behaved as a monotonic function of the membrane potential by increasing in amplitude during hyperpolarization. In addition, the PDS peak amplitude showed a much greater rate of increase than the early EPSP peak amplitude, thus suggesting that the synaptic conductance underlying the PDS was much greater. Perfusion of the neocortical slices with the N-Methyl-D-aspartate (NMDA) receptor antagonist DL-2-amino-phosphonovaleric acid (APV) reduced both the duration and the amplitude of the paroxysmal field discharge in a dose related fashion. The effects of APV were reflected intracellularly by an attenuation of the PDS's late phase and a blockade of the afterdischarge. Similar findings were also obtained by using the NMDA receptor antagonist 3-((+-)-2-carboxypiperazin-4-yl)-propyl-1-phosphonic acid. These data indicate that reduction or blockade of the GABAA receptor is sufficient to elicit epileptiform discharges in the human neocortex maintained in vitro. Mechanisms dependent upon the NMDA receptor contribute to this type of epileptiform response mainly by prolonging the stimulus-induced depolarizing potential and the associated burst of firing.

[Detection of thrombin-antithrombin complexes in hypercoagulability conditions. Analysis of 182 cases]

The detection of TATC may inform about the presence of thrombin generation and, and hence of a pre-thrombotic status. An ELISA test (Enzygnst TAT) has been developed here in order to evaluate the predictive role played by TATC, and it was applied on 182 patients who distributed in 14 with cirrhosis of the liver, 11 with sepsis, 17 with chronic arterial insufficiency, 55 with neoplasms, 9 with thrombosis, 15 in postoperative period, 15 with pneumonia, 16 with disseminated intravascular coagulation (DIC), 14 with multiple injuries and 16 with pancreatitis. TATC levels were significantly increased in all groups with regard to the control group. Patients with thrombosis, sepsis, multiple injuries, DIC and in the postoperative period showed especially high TATC figures. No correlation between TATC and fibrinogen, platelet count, activated partial thromboplastin time or prothrombin complex assay was found in the post-operative patient-group. It was concluded that TATC are a good indicator of hypercoagulability.

[Importance of antiphosphatidylserine antibodies in patients with lupus anticoagulant. Analysis of 30 cases]

Anti-phosphatidylserine (APS) and anticardiolipin (ACL) antibodies were measured in 30 patients with lupus anticoagulant. In 17 cases there were clinical features of thrombosis (56.7%). The number of patients with IgG APS and ACL levels higher than seven standard deviations from the normal mean was significantly higher in the group with thrombosis (p less than 0.017 and p less than 0.02, respectively). The IgG APS level was higher in the group without systemic lupus erythematosus (p less than 0.029). There was a positive correlation between IgG APS and the activated thromboplastin time (r = 0.654, p less than 0.001). The correlation between IgG APS and IgG ACL was rho = 0.61. Two of the 5 patients with increased IgG APS and normal IgG ACL had thrombosis. We think that, in this group of patients, IgG APS titer may be, like IgG ACL, a biological marker of thrombosis risk.

Effects of different dose levels and vaccination schedules on immune response to a recombinant DNA hepatitis B vaccine in haemodialysis patients

Hepatitis B is a frequent complication in haemodialysis patients because of their repeated exposure to blood products, and their impaired cellular and humoral response; trials with plasma-derived hepatitis B vaccine (PDV) show lower immune responses than those in healthy adults. Using a yeast-derived hepatitis B vaccine (YDV), the immunogenicity of two different dose levels (20 and 40 micrograms) and three vaccination schedules were compared in over 270 seronegative dialysis patients. Vaccination with 40 micrograms gave slightly better results than with the 20 micrograms dose. Seroconversion rates were higher with four dose, 40 micrograms vaccination schedules than a three dose schedule, and ranged from 80 to 86%. As the 40 micrograms, 0, 1, 2, 6 month schedule leads to a more rapid rise in antibody levels than the 40 micrograms, 0, 1, 2, 12 month schedule, it appears to be the most appropriate schedule in this patient group.

Immunogenicity of a yeast-derived hepatitis B vaccine in hemodialysis patients

In a multicenter study of hemodialysis patients in Spain, the immunogenicity of a yeast-derived recombinant deoxyribonucleic acid hepatitis B vaccine was evaluated. Two different vaccination schedules were examined: zero, one, two, six months and zero, one, two, 12 months. Two different dose levels (20 micrograms and 40 micrograms) were also compared. No serious adverse effects were reported by any of the vaccinees; the most frequently reported reaction was soreness at the injection site. This study also indicated that higher concentrations of antibodies are attained when more frequent doses of vaccine are administered. The yeast-derived vaccine produced an immune response similar to that of the plasma-derived vaccines.

Maintaining mosquito cell lines at high temperatures: effects on the replication of flaviviruses

The upper thermal limit for maintenance of eleven mosquito cell lines was studied. Although most cell lines could be grown at 32 degrees C to 34 degrees C, Anopheles stephensi cell line could be maintained at 37 degrees C. At higher temperatures initial growth rate was higher, but yield of cells after about a week of incubation was lower than at the standard temperature (28 degrees C). Replication of several flaviviruses in Aedes albopictus cell cultures adapted to 34.5 degrees C was faster, and viral titers were higher than at 28 degrees C.

Plasma and urinary heparin cofactor II levels in patients with nephrotic syndrome

Heparin cofactor II (HC II) levels were measured by electroimmunoassay in plasmas and urines from 68 patients with nephrotic syndrome. In addition, antithrombin III (AT III) and protein C (PC) activities and antigens were measured also in the same group of patients. Seven of these patients had histories of thrombosis. Plasma HC II levels (mean +/- SD 105 +/- 43) were not different from levels in healthy subjects (94 +/- 17). Only 5 patients had low plasma levels of HC II. None of the patients with thrombosis had low HC II levels. Even though measurable amounts of HC II were found in 25 urines from 50 patients. There was a relationship in the urinary excretion between HC II and AT III and their urinary clearances were quite similar. However, no correlation was found between plasma HC II and AT III levels, and levels of AT III activity and antigen were significantly lower than in healthy subjects. Three patients with histories of thrombosis had low AT III levels. Most patients (including those with thrombosis histories) had high plasma PC levels and increased urinary loss. It is suggested that HC II does not play an important role in the pathogenesis of thrombosis in nephrotic syndrome.

Managing the transition to a neuroscience unit

Converting a general medical-surgical unit to a 35-bed neuroscience unit can be both a stressful and a rewarding experience. During a six-month period, from February to September 1983, the authors were involved in transition to a stand-alone neuroscience unit. This article attempts to share their experience with professional nurses who are contemplating or involved in a similar unit change. The article focuses on: 1) a discussion of administrative/management responsibilities; 2) the development of neuroscience educational programs; and 3) program assessment and recommendations.

[Growth retardation, GH deficiency, hyperprolactinemia and delayed puberty]

A case of a male eleven years and three months old, brought to medical attention for short height, is reported. A deficiency of growth hormone associated with hyperprolactinemia without previous clinical manifestations is appreciated in endocrinological study. Detectable tumor is not apparent in any of the investigations performed. HGH and bromocriptine therapy is initiated, resulting in and increase in height and a decrease of prolactin. Currently, at fifteen years four months of age, clinical and analytical data suggest a case of hypogonadism and puberal retardation as well.

Comparative sensitivity of three mosquito cell lines for isolation of dengue viruses

Comparative studies were carried out on three mosquito cell lines (C6/36 clone of Aedes albopictus, AP-61 from A. pseudoscutellaris, and TRA-284 from Toxorhynchites amboinensis) to determine their sensitivity to dengue virus isolation, growth, and handling characteristics for immunofluorescent testing. Virus isolation rates from human sera were the highest in the TRA-284-SF (a line adapted to serum-free medium), followed by the TRA-284 parental line and AP-61. Virus isolation was the lowest in the C6/36 line. All 3 cell lines were comparable in terms of ease of handling, but C6/36 cells were preferable for detecting infected cells by the direct fluorescent antibody test (DFAT) because of frequent cell clumping in the AP-61 and TRA-284 lines. Early detection of viral antigen of all 4 serotypes in the infected cells by DFAT was dependent upon the virus titre in the serum. The AP-61 and TRA-284-SF cells were the best for early detection and identification of viral antigen. Similarly, both AP-61 and TRA-284 cells were more resistant than C6/36 cells to toxic effects of human sera. Based on the economy of using the serum-free medium, their higher sensitivity for dengue virus isolation, and their ease of handling, it is recommended that the TRA-284-SF cell line be used for routine dengue virus isolation in laboratories with cell culture capability.

[Precocious pseudopuberty secondary to granulosa cell tumor]

A case report of pseudoprecocity secondary to a unilateral ovarian tumor of granulosa cells is presented in a 13 month old female. Clinical manifestations appeared at two months of age as unilateral enlargement of the breast, development of pubic hair and vaginal discharge. Plasma estrogen levels were elevated, whereas there was no response of FSH and LH to LH-RH stimulation. The absence of a palpable abdominal mass and a normal ultrasound examination of the abdomen must be pointed out in our case. The suspected clinical and laboratory diagnosis was later confirmed by surgical abdominal examination and ovarian histopathology study. With the exception of a minimal breast enlargement which persists at two years of age, all other signs of pseudoprecocity have disappeared after the surgical removal of the neoplasm. The importance of surgical abdominal examination must be pointed out as a diagnostic method when clinical and laboratory findings suggest an ovarian tumor inspite of normal abdominal palpation, ultrasound and roentgenology.

Mosquito cell cultures and specific monoclonal antibodies in surveillance for dengue viruses

During the fall of 1981, a new method for the routine isolation and identification of dengue viruses in Puerto Rico was implemented utilizing C6/36 cell cultures and serotype specific antidengue monoclonal antibodies. A blind comparison of the monoclonal antibody indirect fluorescent antibody test (IFAT) and the complement fixation (CF) test for identification of 89 newly isolated dengue viruses of all four serotypes from the Caribbean, Asia and Africa showed 100% agreement. Although virus isolation rates were slightly lower than with the mosquito inoculation technique, use of the C6/36 cell culture system was much less time-consuming and allowed the processing of larger numbers of sera. Beginning in November 1981, a new virologic surveillance system was begun in Puerto Rico. Acute sera from persons with suspected dengue were selected for virus isolation attempts on the basis of geographic area of residence on the island, day after onset the blood was taken and clinical signs and symptoms. These sera were processed for virus isolation in C6/36 cell cultures, and virus isolates were identified by the IFAT using the monoclonal antibodies. Using this system, 2,702 sera were tested from November 1981 through August 1982. Dengue virus was isolated from 518, for an isolation rate of 19.2%. Dengue 1 was the predominant virus until December 1981, when dengue 4 became dominant. The changing patterns of dengue 1 and 4 distribution by time and geographic location on Puerto Rico were followed. This system allows the dengue viruses being transmitted in an area to be monitored with a minimal amount of effort and provides the early warning capability necessary to predict epidemic dengue.