[Dextropropoxyphene hepatotoxicity: four cases and literature review]

We report 4 cases of hepatic injury in patients treated with a dextropropoxyphene-paracetamol combination in which the causal relationship with dextropropoxyphene can be suspected. These four cases show similarities with the 29 cases found in international publications. Hepatotoxicity occurs more frequently among old patients and women. Clinically, this condition can mimic a biliary tract disease with sometimes few or no symptoms. Biochemical criteria can show cholestatic, mixed or cytolytic hepatitis. Intrahepatic cholestasis may be found in liver biopsies sometimes suggesting cholangitis. Outcome is favourable on withdrawal of the drug. The mechanism of action of dextropropoxyphene is discussed.

Concentration-effect relationship of cisatracurium at three different dose levels in the anesthetized patient

BACKGROUND

The linearity of cisatracurium elimination and its concentration-effect relation were determined as part of a traditional rich data study with three dose levels in patients receiving balanced anesthesia.

METHODS

Forty-eight adults with American Society of Anesthesiologists status I-II were randomized to receive an intravenous bolus dose of 0.075, 0.15, or 0.30 mg/kg cisatracurium. Anesthesia was induced and maintained with nitrous oxide-oxygen, propofol, and fentanyl. The mechanical response of the adductor pollicis muscle was recorded. Arterial blood samples were collected over 8 h. Cisatracurium, laudanosine, and the monoquaternary alcohol concentrations were measured by high-performance liquid chromatography. To assess the relative contribution of the input function, a parametric (assuming elimination from both the central and peripheral compartments) and a nonparametric pharmacokinetic-pharmacodynamic model were both applied to data.

RESULTS

Dose proportionality of the body disposition of cisatracurium and its two major metabolites at doses up to 0.30 mg/kg was confirmed. With the parametric approach, the effect compartment concentration at 50% block (EC50) significantly increased with the dose (136 vs. 157 vs. 209 ng/ml), whereas the effect compartment equilibration rate constant decreased (0.0675 vs. 0.0568 vs. 0.0478 min(-1)). A similar dose-dependent effect of the pharmacokinetic-pharmacodynamic relation was observed with the nonparametric approach, but the trend was 50% less pronounced.

CONCLUSION

A dose-related change in pharmacokinetic-pharmacodynamic parameters was identified with both modeling approaches. A pharmacokinetic origin was ruled out, although no definite explanation of the underlying mechanism could be provided. These findings suggest that doses relevant to the anesthetic practice be used for estimation of EC50.

Caspase-2 deficiency prevents programmed germ cell death resulting from cytokine insufficiency but not meiotic defects caused by loss of ataxia telangiectasia-mutated (Atm) gene function

It is well established that programmed cell death claims up to two-thirds of the oocytes produced during gametogenesis in the developing fetal ovaries. However, the mechanisms underlying prenatal germ cell loss in females remain poorly understood. Herein we report that caspase-11 null female mice are born with a reduced number of oocyte-containing primordial follicles. This phenotype is likely due to failed cytokine processing known to occur in caspase-11 mutants since neonatal female mice lacking both interleukin (IL)-1alpha and IL-1beta also exhibit a reduced endowment of primordial follicles. In addition, germ cell death in wild-type fetal ovaries cultured ex vivo is suppressed by either cytokine, likely via ligand activation of type 1 IL-1 receptors expressed in fetal germ cells. Normal oocyte endowment can be restored in caspase-11 null female mice by simultaneous inactivation of the gene encoding the cell death executioner enzyme, caspase-2. However, caspase-2 deficiency cannot overcome gametogenic failure resulting from meiotic recombination defects in ataxia telangiectasia-mutated (Atm) null female mice. Thus, genetically distinct mechanisms exist for developmental deletion of oocytes via programmed cell death, one of which probably functions as a meiotic quality-control checkpoint that cannot be overridden.

Intrathecal fentanyl does not modify the duration of spinal procaine block

PURPOSE

To document the clinical characteristics of spinal procaine with or without the addition of fentanyl in light of the failure rate observed previously with procaine 10%.

METHODS

In a randomized, prospective, double-blind study, 52 patients received spinal anesthesia with 100 mg procaine and either saline 0.9% (0.4 ml) (CONTROL group) or 20 microg fentanyl (0.4 ml) (FENTANYL group). Sensory anesthesia to needle prick was evaluated each minute for ten minutes, every three minutes for 33 minutes and every five minutes until regression to T10. Motor block was assessed with the Bromage scale. Patients were questioned by telephone for pain suggesting transient radicular irritation (TRI) 48 hr later.

RESULTS

Mean time to reach highest sensory level, maximum number of segments blocked and mean time for regression of the sensory level to T10 showed no difference. Time to recuperate to full flexion of knees and feet (Bromage 4) showed no difference. Nine patients had nausea (five in CONTROL group and four in FENTANYL group) and nine had pruritus (three in CONTROL group and six in FENTANYL group). No patient reported pain suggesting TRI.

CONCLUSION

Spinal procaine is appropriate for short-duration surgery. Fentanyl does not change the characteristics of the block or the incidence of side effects associated with spinal procaine.

Spinal anesthesia: a comparison of procaine and lidocaine

PURPOSE

To compare spinal procaine to spinal lidocaine with regard to their main clinical characteristics and incidence of transient radicular irritation (TRI).

METHODS

In this randomized, double-blind, prospective study, patients (two groups, n=30 each) received either 100 mg of lidocaine 5% in 7.5% glucose (Group L) or 100 mg of procaine 10% diluted with 1 ml cerebrospinal fluid (Group P). After spinal anesthesia, segmental level of sensory block was assessed by pinprick. Blood pressure and the height of the block were noted each minute for the first ten minutes, then every three minutes for the next 35 min and finally every five minutes until regression of the block to L4. Motor blockade was evaluated using the Bromage scale. To evaluate the presence of TRI, each patient was questioned 48 hr after surgery.

RESULTS

Time to highest sensory level and to maximum number of segments blocked showed no difference between groups. Mean time for sensory regression to T10 and for regression of the motor block were shorter in Group P. Eighty minutes following injection, sensory levels were lower in Group P. Five patients had inadequate surgical anesthesia in Group P and only one in Group L. No patient in Group P had TRI (95% CI 10-12%) while eight (27%) in Group L did (95% CI 12-46%).

CONCLUSIONS

Procaine 10% was associated with a clinical failure rate of 14.2%. This characteristic must be balanced against an absence of TRI, which occurs more frequently with the use of lidocaine 5%.

Correlates of mental disorders in the Quebec general population of 6 to 14-year olds

Previous epidemiological studies of correlates of child and adolescent mental disorders in the general population have focused more on child/adolescent and socioeconomic/sociodemographic characteristics than on family characteristics. Moreover, there are no generally accepted methods to analyze and interpret correlates. The purpose of the Quebec Child Mental Health Survey in this regard was twofold: (1) to identify correlates of DSM-III-R internalizing and externalizing disorders according to informant (youth, parent, teacher), for three age groups (6-8, 9-11, and 12-14 years), including relevant family characteristics not considered in previous studies; and (2) to interpret the relative importance of risk indicators by ranking correlates according to strength and consistency of association across age groups. Logistic regression models suggest the inconsistency of correlates across informants. The ranking of correlates reveals that individual and family characteristics make a more important contribution than do socioeconomic characteristics, thereby supporting the relevance of proximal variables in the development of psychopathology.

The Dominic-R: a pictorial interview for 6- to 11-year-old children

OBJECTIVE

To review the Dominic-R and the Terry questionnaires, respectively, for white and African-American children, both DSM-III-R-based, and more recent DSM-IV-based computerized versions.

METHOD

Five papers describing the development, content, validation studies, and establishment of the diagnostic cutpoints of these instruments are reviewed. The instruments are pictorial, fully structured, and designed to assess mental disorders in children 6 to 11 years of age. Symptom descriptions complement the visual stimulus, providing better information-processing than visual or auditory stimuli alone. Cognitive immaturity of young children bars frequency, duration, and age-of-onset measurements, restricting correspondence with DSM criteria. DSM-IV (computerized versions) and DSM-III-R (paper versions) disorders being assessed include specific (simple) phobias, separation anxiety, generalized anxiety (overanxious), depression/dysthymia, attention-deficit hyperactivity, oppositional defiant, and conduct disorder.

RESULTS

Test-retest reliability of symptoms and symptom scores and criterion validity against clinical judgment support the visual-auditory combination of stimuli to assess child mental health.

CONCLUSION

Intended for clinical, epidemiological, and screening purposes, these instruments are short and simple. Although it only approximates DSM-III-R and DSM-IV criteria, the pictorial format permits young children to be reliable informants about their mental health.

Spinal procaine with and without epinephrine and its relation to transient radicular irritation

PURPOSE

To document the clinical characteristics of procaine with or without the addition of epinephrine.

METHODS

In this randomized, prospective, double blind study, 62 patients received spinal anesthesia with 100 mg procaine and either 0.3 mg epinephrine (EPI group) or 0.3 ml NaCl 0.9% (SALINE group). Sensory anesthesia to needle prick was evaluated q 1 min for 10 min, q 3 min for 33 min and q 5 min until regression to L4. Motor block was assessed with the Bromage scale. Patients were questioned, by telephone, for transient radicular irritation (TRI) 48 hr later.

RESULTS

Time to reach highest sensory level and number of segments blocked showed no difference. Mean time for regression of the sensory level to T10 was longer in EPI (83 +/- 23 vs 66 +/- 20 min, P < 0.01). Time to recuperate to full flexion of knees and feet (Bromage 4) was longer in EPI (126 +/- 37 vs 100 +/- 30 min, P < 0.01). Patients in EPI received more ephedrine. Eighteen patients had nausea (15 EPI/3 SALINE, P < 0.0015). One patient had TRI, incidence: 1.67%, 95% CI (< 1%-9%).

CONCLUSION

Spinal procaine is appropriate for surgery of short duration. Epinephrine prolongs sensory and motor blocks by 25%. However, it is associated with a high incidence of nausea.

Quebec child mental health survey: prevalence of DSM-III-R mental health disorders

The Quebec Child Mental Health Survey (QCMHS) was conducted in 1992 on a representative sample of 2400 children and adolescents aged 6 to 14 years from throughout Quebec. Prevalences of nine Axis-I DSM-III-R (American Psychiatric Association, 1987) mental health disorders were calculated based on each informant (for 6-11-year-olds: child, parent, and teacher; for 12-14-year-olds: child and parent). Informant parallelism allows the classification of results of the demographic variables associated with disorders in the logistic regression models. This strategy applies to group variables (correlates of disorders) whereas informant agreement applies to individual diagnoses. Informant parallelism implies that results for two informants or more are in the same direction and significant. In the QCMHS, informant parallelism exists for disruptive disorders, i.e. in two ADHD regression models (child and parent) higher rates among boys and young children, and in three oppositional/conduct disorders regression models (child, parent, and teacher) higher rates among boys. No informant parallelism is observed in the logistic regression models for internalizing disorders, i.e. the patterns of association of demographic variables with anxiety and depressive disorders vary across informants. Urban-rural residence does not emerge as a significant variable in any of the logistic regression models. The overall 6-month prevalences reach 19.9% according to the parent and 15.8% according to the child. The implications of the results for policy makers and clinicians are discussed.

Diagnostic Interview Schedule for Children (DISC-2.25) in Quebec: reliability findings in light of the MECA study

OBJECTIVE

To examine the reliability of the French Diagnostic Interview Schedule for Children (DISC-2.25) in Quebec in light of other DISC-2 studies conducted in the National Institute of Mental Health's Methods for the Epidemiology of Child and Adolescent Mental Disorders Study.

METHOD

Reliability was assessed for DSM-III-R disorders in a community sample comprising 260 parents of youths aged 6 to 14 years and 145 adolescents aged 12 to 14 years. The DISC was completed at home. The mean test-retest interval was 13.8 days for parents and 12.8 days for adolescents.

RESULTS

Parents' reports: Internal consistency was acceptable for a majority of disorders. The kappa coefficients were in the fair or good ranges except for depressive disorders and were higher for children than for adolescents, and intraclass correlations were higher than kappa coefficients. Adolescents' reports: Internal consistency was acceptable or nearly acceptable for a majority of disorders. The kappa coefficients were in the fair range, and intraclass correlations were higher than kappa coefficients. The kappa coefficients were significantly higher for the test-retest interval of 7 to 14 days than for 14 to 21 days for adolescents' reports of anxious disorders and internalizing disorders.

CONCLUSION

The French DISC-2.25 shows acceptable internal consistency and fair to good test-retest reliability. Across DISC-2 studies, test-retest reliability of the parents' reports improved for anxiety and depressive disorders. Among sources of variation, studies on attributes of questions would be meaningful.

Reliability of the Terry: a mental health cartoon-like screener for African-American children

Test-retest reliability and internal consistency of the Terry, a cartoon-based child mental health screener developed for African-American children, were measured in 36 boys (age 5 1/2 to 13) in a test-retest design. Reliability of the diagnosis (0.70 < or = k < or = 0.75) was good for ADHD, ODD, CD, and OAD, and excellent for MDD and SAD. Because of low base-rate, no kappa value was calculated for SPh. Both test-retest agreement, and reliability of the symptom scale (0.75 < or = ICC < or = 0.80) were very good for all 7 diagnoses. Internal consistency according to symptom scale (0.78 < or = Cronbach alpha < or = 0.90), was moderate for OAD, good for SPh, MDD, SAD, CD, and ODD, and excellent for ADHD. The Terry is a culturally-sensitive questionnaire with good reliability.

Defects in regulation of apoptosis in caspase-2-deficient mice

During embryonic development, a large number of cells die naturally to shape the new organism. Members of the caspase family of proteases are essential intracellular death effectors. Herein, we generated caspase-2-deficient mice to evaluate the requirement for this enzyme in various paradigms of apoptosis. Excess numbers of germ cells were endowed in ovaries of mutant mice and the oocytes were found to be resistant to cell death following exposure to chemotherapeutic drugs. Apoptosis mediated by granzyme B and perforin was defective in caspase-2-deficient B lymphoblasts. In contrast, cell death of motor neurons during development was accelerated in caspase-2-deficient mice. In addition, caspase-2-deficient sympathetic neurons underwent apoptosis more effectively than wild-type neurons when deprived of NGF. Thus, caspase-2 acts both as a positive and negative cell death effector, depending upon cell lineage and stage of development.

Sealing one's fate: control of cell death in neurons

BCL-2 family members and caspases are essential components of the death machinery in neurons. Identification of Apaf-1 as the mammalian homologue of Caenorhabditis elegans ced-4 provided the final proof of the complete conservation of the C. elegans programmed cell death pathway in mammals. When neurons are deprived of trophic factors, a sequence of events is initiated, which includes a reduction in macromolecule synthesis, elevation of c-Jun and cyclin D1, and activation of BAX. The final episode of this sequence is the activation of caspases, which may mark the death commitment point at which neurons cannot be rescued by addition of trophic factors. In addition, recent evidence suggests that the components in the developmental programmed cell death pathway may play a critical role in neurodegenerative disorders.

Reliability of the Dominic-R: a young child mental health questionnaire combining visual and auditory stimuli

Reliability of the Dominic-R, a questionnaire combining visual and auditory stimuli, was tested in 340 community children aged 6 to 11 years. Test-retest reliability of symptoms of, and symptom scores of, DSM-III-R disorders including simple phobias, separation anxiety disorder, overanxious disorder, depression/dysthymia, attention deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder was assessed. Most symptoms yielded kappas greater than .40, and ICCs ranged from .74 to .81. In conclusion, reliability of the Dominic-R compares favourably with that of other child assessment questionnaires.

Activation of caspase-2 in apoptosis

Members of the CED-3/interleukin-1beta-converting enzyme (ICE) protease (caspase) family are synthesized as proforms, which are proteolytically cleaved and activated during apoptosis. We report here that caspase-2 (ICH-1/NEDD-2), a member of the ICE family, is activated during apoptosis by another ICE member, a caspase-3 (CPP32)-like protease(s). When cells are induced to undergo apoptosis, endogenous caspase-2 is first cleaved into three fragments of 32-33 kDa and 14 kDa, which are then further processed into 18- and 12-kDa active subunits. Up to 50 microM N-acetyl-Asp-Glu-Val-Asp-aldehyde (DEVD-CHO), a caspase-3-preferred peptide inhibitor, inhibits caspase-2 activation and DNA fragmentation in vivo, but does not prevent loss of mitochondrial function, while higher concentrations of DEVD-CHO (>50 microM) inhibit both. In comparison, although the activity of caspase-3 is very sensitive to the inhibition of DEVD-CHO (<50 nM), inhibition of caspase-3 activation as marked by processing of the proform requires more than 100 microM DEVD-CHO. Our results suggest that the first cleavage of caspase-2 is accomplished by a caspase-3-like activity, and other ICE-like proteases less sensitive to DEVD-CHO may be responsible for activation of caspase-3 and loss of mitochondrial function.

Characterization of the avian Ich-1 cDNA and expression of Ich-1L mRNA in the hen ovary

We have sequenced the chicken interleukin-1beta-converting enzyme (ICE) and ced-3 homolog (Ich-1) cDNA, and evaluated Ich-1 mRNA expression in the hen ovary during follicle development. While two alternatively spliced forms of Ich-1, Ich-1L and Ich-1S, were amplified by PCR from an embryonic chicken cDNA library, only the Ich-1L form was found to be expressed in adult ovarian granulosa and theca tissues. The deduced amino acid (aa) sequence of ICH-1L is 70.8% identical to human ICH-1L and contains the conserved QACRG peptide active catalytic sequence characteristic of many ICE-related family of cysteine proteases.

Specific cleavage of alpha-fodrin during Fas- and tumor necrosis factor-induced apoptosis is mediated by an interleukin-1beta-converting enzyme/Ced-3 protease distinct from the poly(ADP-ribose) polymerase protease

Interleukin-1beta-converting enzyme (ICE)/Ced-3 proteases play a critical role in apoptosis. One well characterized substrate of these proteases is the DNA repair enzyme poly(ADP-ribose) polymerase. We report here that alpha-fodrin, an abundant membrane-associated cytoskeletal protein, is cleaved rapidly and specifically during Fas- and tumor necrosis factor-induced apoptosis; this cleavage is mediated by an ICE/Ced-3 protease distinct from the poly(ADP-ribose) polymerase protease. Studies in cells treated with these apoptotic stimuli reveal that both fodrin and poly(ADP-ribose) polymerase proteolysis are inhibited by acetyl-Tyr-Val-Ala-Asp chloromethyl ketone and CrmA, specific inhibitors of ICE/Ced-3 proteases. However, fodrin proteolysis can be distinguished from poly(ADP-ribose) polymerase proteolysis by its relative insensitivity to acetyl-Asp-Glu-Val-Asp aldehyde (DEVD-CHO), a selective inhibitor of a subset of ICE/Ced-3 proteases that includes CPP32. DEVD-CHO protects cells from Fas-induced apoptosis but does not prevent fodrin proteolysis, indicating that cleavage of this protein can be uncoupled from apoptotic cell death. Moreover, purified fodrin is cleaved in vitro by CPP32 (but not by ICE) into fragments of the same size observed in vivo during apoptosis. These findings suggest that fodrin proteolysis in vivo may reflect the activity of multiple ICE/Ced-3 proteases whose partial sensitivity to DEVD-CHO reflects a limited contribution from CPP32, or an ICE/Ced-3 protease less sensitive than CPP32 to DEVD-CHO inhibition.

Activation of an interleukin 1 converting enzyme-dependent apoptosis pathway by granzyme B

Cytotoxic T lymphocytes (CTL) can induce apoptosis through a granzyme B-based killing mechanism. Here we show that in cells undergoing apoptosis by granzyme B, both p45 pro-interleukin 1 beta converting enzyme (ICE) and pro-CPP32 are processed. Using ICE deficient (ICE -/-) mice, embryonic fibroblasts exhibit high levels of resistance to apoptosis by granzyme B or granzyme 3, while B lymphoblasts are granzyme B-resistant, thus identifying an ICE-dependent apoptotic pathway that is activated by CTL granzymes. In contrast, an alternative ICE-independent pathway must also be activated as ICE -/- thymocytes remain susceptible to apoptosis by both granzymes. In ICE -/- B cells or HeLa cells transfected with mutant inactive ICE or Ich-1S that exhibit resistance to granzyme B, CPP32 is processed to p17 and poly(ADP-ribose) polymerase is cleaved indicating that this protease although activated was not associated with an apoptotic nuclear phenotype. Using the peptide inhibitor Ac-DEVD-CHO, apoptosis as well as p45 ICE hydrolysis are suppressed in HeLa cells, suggesting that a CPP32-like protease is upstream of ICE. In contrast, p34cdc2 kinase, which is required for granzyme B-induced apoptosis, remains inactive in ICE -/- B cells indicating it is downstream of ICE. We conclude that granzyme B activates an ICE-dependent cell death pathway in some cell types and requires a CPP32-like Ac-DEVD-CHO inhibitable protease acting upstream to initiate apoptosis.

Effects of human immunodeficiency virus type 1 infection on programmed cell death in the presence or absence of Bcl-2

The effect of human immunodeficiency virus (HIV-1) infection on the programmed cell death of CD4+ lymphocytes was studied by using Jurkat cells stably expressing high levels of the Bcl-2 protein (Jurkat-Bcl2) or control cells (Jurkat-P). Both Jurkat-Bcl2 and Jurkat-P cells exhibited surface CD4 expression adequate to support HIV-1 infection. We observed no differences between HIV-1-infected Jurkat Bcl2 cells and control cells with respect to kinetics of virus replication, protein expression, and processing. Severe cytopathic effects, which were typical of acute HIV-1 infection and consisted of syncytium formation followed by single-cell lysis, were observed in both cell types. However, several lines of evidence, such as cell viability analysis by trypan blue dye exclusion, chromosomal DNA laddering, and morphologic analysis by acridine orange/ethidium bromide or Giemsa staining, indicated that HIV-1 did not induce a significant amount of programmed cell death in either cell type. These results suggest that apoptosis is at most a minor element in HIV-1-induced cytopathicity in Jurkat lymphocytes.

Do children aged 9 through 11 years understand the DISC Version 2.25 questions?

OBJECTIVE

To assess the understanding of Diagnostic Interview Schedule for Children-Version 2.25 (DISC-2.25) questions by children aged 9 through 11 years.

METHOD

Two hundred forty children were recruited from four public schools. The cognitive appraisal of 280 questions from the most prevalent DSM-III-R diagnoses was evaluated. The collaboration of four children was necessary to cover one DISC. Sixty DISCs, evenly distributed according to age and sex, were completed. Two child psychiatrists evaluated the children's answers. Nonparametric tests were used to assess understanding of questions as a whole, of time concepts (overall, categories, number), and of questions based on the number of words.

RESULTS

Children aged 9, 10, and 11 years understood 38%, 38%, and 42% of the questions as a whole, respectively, and 26%, 24%, and 30% of the overall time concepts, respectively. The understanding rates of questions as a whole were significantly higher than those of overall time concepts. Durations were significantly better understood than periods and frequencies, and questions having one time component were significantly better grasped than those with two or more. Shorter questions were significantly better understood than longer ones.

CONCLUSION

Although the DISC has been greatly improved since the initial version, the results suggest that additional revision is needed before clinicians or researchers use the DISC with younger children.

An empirical comparison between the DSM and psychodynamic approaches for assessment of child disorders in children attending outpatient clinics

The DSM and psychodynamic approaches provide different perspectives on child psychiatric diagnoses. Taking advantage of the recent publication of a psychodynamically oriented classification of child disorders, correspondences between these approaches were studied in a sample of outpatient clinic children. Clinician judges and a psychiatric interview schedule provided for diagnoses. Classifications of child psychopathology are still imperfect to a large extent. As a result, statistical comparisons can only yield limited relationships and caution is necessary when using classification tools. Methodological difficulties notwithstanding, various associations showed that DSM and psychodynamic constructs, while different, are not entirely independent.

Ich-1, an Ice/ced-3-related gene, encodes both positive and negative regulators of programmed cell death

We report here the isolation and characterization of Ich-1, a gene related to the C. elegans cell death gene ced-3 and the mammalian homolog of ced-3, interleukin-1 beta-converting enzyme (ICE). Alternative splicing results in two distinct Ich-1 mRNA species. One mRNA species encodes a protein product of 435 amino acids (ICH-1L) that is homologous to both the P20 and P10 subunits of ICE (27% identity) and the entire CED-3 protein (28% identity). The other mRNA encodes a 312 amino acid truncated version of ICH-1L protein (ICH-1S). Overexpression of IchL induces programmed cell death, suggesting that Ich-1 is also a mammalian programmed cell death gene. More interestingly, overexpression of the Ich-1S suppresses Rat-1 cell death induced by serum deprivation. These observations suggest that Ich-1 plays an important role in both positive and negative regulation of programmed cell death in vertebrate animals.

A structured pictorial questionnaire to assess DSM-III-R-based diagnoses in children (6-11 years): development, validity, and reliability

This paper presents a structured pictorial instrument, the Dominic questionnaire, to assess mental disorders in 6- to 11-year-old children. Ninety-nine drawings represent situations corresponding to DSM-III-R based ADHD, CD, ODD, MDD, SAD, OAD, and SPh. However, cognitive limitation of 6- to 11-year-old children do not allow for time-related measurement. The instrument takes 15-20 min to administer. Reliability and validity of the Dominic questionnaire were studied in Parent DISC-2 positive and negative outpatient and general population samples and against clinical judgement. The pictorial approach provides acceptable test-retest reliability and the instrument makes standardized assessment possible for children as young as 6 years of age.

Possible red-man syndrome associated with systemic absorption of oral vancomycin in a child with normal renal function

OBJECTIVE

To report possible red-man syndrome (RMS) associated with oral administration of vancomycin.

CASE SUMMARY

A 23-month-old child with acute myeloblastic leukemia developed symptoms compatible with RMS while receiving oral vancomycin for suspected Clostridium difficile colitis. Serum concentrations of vancomycin, measured at the time of the clinical episode, demonstrated significant oral absorption of the drug. Serum concentrations of vancomycin decreased later, implying a possible decrease in absorption, after the patient's neutrophil count returned to normal. The child later experienced another clinical episode compatible with RMS while vancomycin was being administered intravenously for suspected sepsis.

DISCUSSION

There is no published report of RMS following oral administration of vancomycin. The reaction described took place while the child was neutropenic. Because of the absence of any significant renal function alteration that could explain the importance of the serum concentrations observed, we assume that C. difficile, neutropenia-, and chemotherapy-associated colitis may have resulted in extensive intestinal lesions, leading to an increased amount of vancomycin being systemically absorbed. This increased absorption during profound neutropenia may have been sufficient to exceed a purported threshold, leading to RMS.

CONCLUSIONS

This case demonstrates that significant absorption of vancomycin may occur in neutropenic patients with normal renal function, and that it may be accompanied by RMS, usually associated with rapid infusions or large parenteral doses of the drug.