Treatment of psychogenic polydipsia: comparison of risperidone and olanzapine, and the effects of an adjunctive angiotensin-II receptor blocking drug (irbesartan)

OBJECTIVE

Our objective was to determine the outcome of novel strategies in managing a case of severe polydipsia.

CLINICAL PICTURE

The patient was a 39-year-old male with a 20-year history of paranoid schizophrenia who, despite only mild residual psychotic symptoms, had been hospitalized for the previous 10 years because of severe polydipsic behaviour complicated by water intoxication.

TREATMENT

Novel antipsychotic agents, risperidone and olanzapine, as well as the specific angiotensin-II receptor blocking drug, irbesartan were employed at selected intervals in a study lasting nearly 3 years. A strict behavioural management programme was ongoing, in which diurnal weight change and the number of breaches of weight limits, requiring management in a low-stimulus environment, were documented on a daily basis. Summary measures of diurnal weight change and behavioural intervention were charted against changes in treatment.

OUTCOME

Polydipsic behaviour improved on risperidone up to 4 mg daily, but was not sustained. Olanzapine was similarly successful in stabilizing polydipsia, and improvement was achieved with the addition of irbesartan.

CONCLUSION

We suggest that the D2-sparing profiles of receptor binding achieved with low-dose risperidone and olanzapine may account for this beneficial effect. The benefit derived with irbesartan implicates the involvement of brain angiotensin systems centrally in helping to regulate drinking behaviour.

History of the professional councils of the National Kidney Foundation

As the Councils move toward the new millennium, efforts to improve outcomes for patients with renal disease will be at the forefront. Each council has established a commitment to improving the quality of life for these individuals. Toward this goal, the CNNT, the CRN, and the CNSW will each propose programs to the NKF for improving the knowledge and skills of the professionals within these councils, promoting research within the respective scope of these professions, and working together to bring a better understanding of the issues confronted by the patients and the professionals as well. As an example of the combined effort of the Councils, the first joint project of the century will be to bring the communications packages of each council under a common framework by joining the newsletters of each council. It is an exciting time to be part of the NKF. As a professional in the renal community, being a part of the CNNT, the CRN, or the CNSW offers a professional enrichment and opportunities to participate in making lives better for those with renal disease.

Targeted insertion of a lacZ reporter gene into the mouse Cer1 locus reveals complex and dynamic expression during embryogenesis

The mouse Cer1 (mCer1, Cer-l, Cerr1) gene encodes one member of a family of cytokines structurally and functionally related to the Xenopus head-inducing factor, Cerberus (xCer). We generated a mouse line in which the Cer1 gene was inactivated by replacing the first coding exon with a lacZ reporter gene. Mice homozygous for this allele (Cer1(lacZ)) showed no apparent perturbation of embryogenesis or later development. However, the lacZ reporter revealed a number of hitherto uncharacterised sites of Cer1 expression in late fetal and adult tissues. Preliminary analysis suggests that Cer1 is not essential for their morphogenesis, differentiation, or homeostasis.

Neuroimaging evidence implicating cerebellum in support of sensory/cognitive processes associated with thirst

Recent studies implicate the cerebellum, long considered strictly a motor control structure, in cognitive, sensory, and affective phenomenon. The cerebellum, a phylogenetically ancient structure, has reciprocal ancient connections to the hypothalamus, a structure important in vegetative functions. The present study investigated whether the cerebellum was involved in vegetative functions and the primal emotions engendered by them. Using positron emission tomography, we examined the effects on the cerebellum of the rise of plasma sodium concentration and the emergence of thirst in 10 healthy adults. The correlation of regional cerebral blood flow with subjects' ratings of thirst showed major activation in the vermal central lobule. During the development of thirst, the anterior and posterior quadrangular lobule, lingula, and the vermis were activated. At maximum thirst and then during irrigation of the mouth with water to alleviate dryness, the cerebellum was less activated. However, 3 min after drinking to satiation, the anterior quadrangular lobule and posterior cerebellum were highly activated. The increased cerebellar activity was not related to motor behavior as this did not occur. Instead, responses in ancient cerebellar regions (vermis, fastigal nucleus, archicerebellum) may be more directly related to vegetative and affective aspects of thirst experiences, whereas activity in neocerebellar (posterior) regions may be related to sensory and cognitive aspects. Moreover, the cerebellum is apparently not involved in the computation of thirst per se but rather is activated during changes in thirst/satiation state when the brain is "vigilant" and is monitoring its sensory systems. Some neocerebellar activity may also reflect an intentionality for gratification by drinking inherent in the consciousness of thirst.

Neuroimaging of genesis and satiation of thirst and an interoceptor-driven theory of origins of primary consciousness

There are defined hypothalamic functions in the genesis of thirst, but little is known of the cortical processes subserving consciousness of thirst notwithstanding the medical disorders that occur in psychiatric illness, addiction, and the attested decline of thirst with aging. In 10 adult males, positron emission tomography scans were made (i) during genesis of moderate thirst by infusion of i.v. hypertonic saline 0.51 M, (ii) after irrigation of the mouth with water to remove the sensation of dryness, and (iii) 3, 14, 45, and 60 minutes after drinking water to fully satiate thirst. The correlation of regional cerebral blood flow with thirst score showed the major activation to be in the posterior cingulate. Maximum thirst sensation evoked 13 highly significant activations and 9 deactivations in cingulate and parahippocampal gyri, insula, thalamus, amygdala, and mesencephalon. It is possible that cingulate sites (Brodmann's areas 32, 24, and 31) that persisted with wet mouth but disappeared immediately after drinking to satiation may have an important role in the consciousness of thirst. Consciousness of thirst, a primal vegetative emotion, and satiation of thirst appear to be subserved by phylogenetically ancient brain regions. This is salient to current discussion on evolutionary emergence of primary consciousness.

Correlation of regional cerebral blood flow and change of plasma sodium concentration during genesis and satiation of thirst

Positron emission tomography studies were conducted during genesis of moderate thirst by rapid i.v. infusion of hypertonic saline (0.51 M) and after satiation of thirst by drinking water. The correlation of regional cerebral blood flow with the change in the plasma Na concentration showed a significant group of cerebral activations in the anterior cingulate region and also a site in the middle temporal gyrus and in the periaqueductal gray. Strongest deactivations occurred in the parahippocampal and frontal gyri. The data are consistent with an important role of the anterior cingulate in the genesis of thirst.

Endoscopic screening for dysplasia and mucosal aneuploidy in adolescents and young adults with childhood onset colitis

OBJECTIVES

In adults, the premalignant nature of ulcerative colitis (UC) has long been accepted. Currently there is increasing concern that Crohn's disease (CD) may be equally premalignant. As a consequence, most adults with long-standing UC and many with chronic CD are enrolled in ongoing endoscopic cancer surveillance programs. In contrast, the risk of colonic cancer in adolescents and young adults with either form of colitis is less well recognized, and the need for dysplasia and cancer screening in this population has not been systematically evaluated. We therefore report the prospective results of colonoscopic cancer screening in such a young population.

METHODS

Thirty-five adolescents and young adults with long-standing colitis (18 UC, 17 CD; 21 +/- 3 yr old, 11 +/- 3 yr colitis duration) underwent colonoscopic cancer screening. All had multiple biopsies for flow cytometry and light microscopy.

RESULTS

Seven subjects had aneuploidy (3/18 UC, 4/17 CD). Of these seven, only two had dysplasia [one high grade (UC), one low grade (CD)]. One additional subject had indefinite dysplasia with normal flow cytometry. The remaining 27 subjects had both normal flow cytometry and light microscopy. Five of the seven aneuploid subjects underwent surgery within 1 yr of screening. Four, including both subjects with dysplasia, had no evidence of colon cancer at surgery. However, a 24-yr-old female with a 14-yr history of UC and no evidence of dysplasia or cancer at screening had a Dukes C adenocarcinoma.

CONCLUSIONS

Adolescents and young adults with childhood onset UC or CD are at risk for aneuploidy, dysplasia, and colon cancer. Aneuploidy can be evident 10 yr after the onset of colitis and in patients as young as 16 yr of age. Therefore, the risk for colon cancer in patients with childhood onset colitis must be based on the duration of the illness, not on their chronological age. Incorporation of flow cytometry into an endoscopic screening protocol appears to enhance the ability to identify individuals at highest risk for colon cancer.

Differential effects of physiological versus pathophysiological plasma concentrations of epinephrine and norepinephrine on ketone body metabolism and hepatic portal blood flow in man

Few studies that have examined the effects of catecholamines on ketogenesis have considered the effects of catecholamines on hepatic portal blood flow. Since hepatic blood flow is a major determinant of hepatic ketogenesis (via modification of free fatty acid availability), interpretation of these studies is difficult. To better define the relative contributions of these variables, we studied the effects of physiological and pathophysiological plasma concentrations of epinephrine and norepinephrine on plasma ketone body concentrations and hepatic portal blood flow in controlled paired studies in young healthy male volunteers. To assess the effects of physiological catecholamine concentrations, each of eight subjects received 60-minute sequential infusions of epinephrine (10 ng/kg/min) and norepinephrine (32.5 ng/kg/min) together with a control infusion of heparin (0.4 U/kg/min) separated by 60-minute washout periods. Similar increments in plasma nonesterified fatty acid ([NEFA] to approximately 1 mmol/L) were observed during each infusion. The ketotic ratios, calculated as the ratio of plasma ketone bodies to fatty acids integrated above baseline for 90 and 120 minutes, respectively, for epinephrine and norepinephrine infusions were both significantly greater (P < .005 for each) than for the heparin control infusion. To assess the effects of pathophysiological plasma catecholamine concentrations, each of eight subjects also received sequential 60-minute infusions of epinephrine 60 ng/kg/min, norepinephrine 80 ng/kg/min (plus heparin 0.1 U/kg/min), and a separate control infusion of heparin with or without Intralipid (KabiVitrum, Alameda, CA). Whereas integrated plasma fatty acid levels were approximately twofold greater than those observed in the physiological protocol, the absolute integrated ketone body response to the pathophysiological concentration of epinephrine was significantly lower than that observed for the physiological dose of the hormone (P < .05). In contrast, the ketotic ratio for norepinephrine was significantly greater (P < .005) than for both epinephrine and the control infusion of heparin with or without Intralipid. Significant (P < .01) increases above baseline fasting levels were observed in plasma glucose and immunoreactive insulin concentrations during infusion of pathophysiological concentrations of epinephrine. Because of the technical difficulties of simultaneously measuring portal blood and sampling blood frequently, studies were repeated in six additional subjects using noninvasive image-guided flowmetry to measure percentage changes in hepatic portal blood flow during catecholamine infusion. Norepinephrine reduced hepatic portal blood flow significantly at the low-physiological concentration by 12% (P < .05) and at the pathophysiological concentration by 18% (P < .05). In summary, (1) both epinephrine and norepinephrine were associated with significant ketotic effects at physiological plasma concentrations; and (2) when infused at pathophysiological concentrations, only norepinephrine exerted a significant additional ketotic effect. Since norepinephrine has a significant simultaneous effect of reducing hepatic portal blood flow, we conclude that previous studies may have underestimated the effect of norepinephrine on hepatic ketogenesis.

Selective expansion of specific T cell receptors in the inflamed colon of Crohn's disease

To identify disease-specific T cell changes that occur in Crohn's disease (CD), the T cell receptor BV repertoires of lamina propria lymphocytes (LPL) isolated from both the inflamed and "disease-inactive" colons of seven CD patients were compared by the quantitative PCR and DNA sequence analysis. It was observed that the BV repertoires of LPL isolated from the disease-active and disease-inactive parts of the colon from the same individual were very different. Furthermore, nearly all of the differences occurred in CD4+ LPL, with very few differences in the CD8+ population of LPL. Although the pattern of BV segments that was increased in disease-active tissue relative to disease-inactive tissue was different for all seven CD patients, there were several BV segments that increased uniformly in the disease-active tissue of all seven individuals. CDR3 length analysis and DNA sequencing of these BV segments revealed that in six of the seven CD patients there was a striking degree of oligoclonality that was absent from disease-inactive tissue of the same individual. These observations suggest that at least some of the inflammation in CD is the result of responses by CD4+ T cells to specific antigens. The isolation of such inflammation-specific CD4+ T cells may make it possible to identify the antigens that are responsible for the inflammatory process in CD and provide a better understanding of its pathogenesis.

CD4+ cell oligoclonality in Crohn's disease: evidence for an antigen-specific response

To identify disease-specific T cell changes that occur in Crohn's disease (CD) the T-cell receptor (TCR) BV repertoires of lamina propria lymphocytes (LPL) from both disease-active and disease-inactive colonic tissue of three CD patients were compared by a quantitative polymerase chain reaction (qPCR) and CDR3 length analysis. It was observed that the BV repertoires of LPL isolated from the disease-active and disease-inactive parts of the colon of the same individual were different, and most of the differences occurred in CD4+ LPL with very few differences in the CD8+ populations of LPL. Although the pattern of BV segments that was increased in disease-active relative to disease-inactive tissue was different for all three CD patients, there was an increase in the levels of BV11, 13S2, 15, 16, and 17 segments in the disease-active tissue of all three patients. Standard CDR3 length analysis of BV11, 13S2, 15, 16, and 17 segments revealed that in two of the three CD patients there was a striking degree of TCR oligoclonality in the disease-active tissue that was absent from disease-inactive tissue of the same individual. Additional differences between the disease-active and disease-inactive tissues were observed using a more refined method of CDR3 length analysis, which employs BV- and BJ-specific primers. These observations suggest that at least some of the inflammation in CD is the result of responses by CD4+ T cells to specific antigens.

Crohn's disease is accompanied by changes in the CD4+, but not CD8+, T cell receptor BV repertoire of lamina propria lymphocytes

To identify disease-specific T cell changes that occur in Crohn's disease (CD), the T cell receptor (TCR) BV repertoires of lamina propria lymphocytes (LPL) isolated from the diseased colon of seven CD patients and eight controls were determined by semiquantitative polymerase chain reaction (qPCR). As an internal control for the effects of HLA and other genes on the TCR repertoire, the BV repertoires of peripheral blood lymphocytes (PBL) from the same individuals were similarly determined and used for comparison. It was observed that the BV repertoires of LPL and PBL within the same individual were very different in both the CD and control groups. However, the CD4+, but not CD8+, repertoires of LPL and PBL differed to a much greater extent in the CD group than in the control group. Furthermore, in each CD patient there was a unique pattern of BV segments which were increased in the CD4+ LPL repertoire relative to that in PBL. These observations suggest that the inflammatory process in CD involves responses by specific CD4+ T cells to specific antigens. The isolation of such inflammation-specific CD4+ T cells may make it possible to identify the antigens which are responsible for the inflammatory process in CD and provide a better understanding of its pathogenesis.

Comparisons of T cell receptor (TCR) V beta repertoires of lamina propria and peripheral blood lymphocytes with respect to frequency and oligoclonality

The TCR repertoires of CD4+ and CD8+ lamina propria and peripheral blood lymphocytes (PBL) were compared with respect to V beta frequencies and oligoclonality. Disease-free colon specimens and paired peripheral blood samples were obtained from eight adult patients undergoing surgical resections for colorectal carcinoma. Mononuclear cell were isolated from the lamina propria and peripheral blood and separated into CD4+ and CD8+ cells by immunomagnetic adsorbtion. Analysis of V beta frequencies by qPCR revealed that PBL and lamina propria lymphocytes (LPL) from the same individual have very different repertoires, especially within the CD8+ population. Furthermore, CD8+, but not CD4+, LPL display extensive oligoclonality, similar to that which has previously been reported for CD8+ PBL. However, the oligoclonal receptors observed in CD8+ LPL are, in general, distinct from those observed in CD8+ PBL, and differ for each individual. These observations indicate that the TCR repertoires of LPL are as diverse as PBL, and suggest that LPL and PBL are normally exposed to different sets of antigens. In addition, these observations provide a baseline for examining the effects of various disease states and environmental insults on the LPL repertoire.

Recruits from other industries. What can they teach you? Interview by John McCormack

When Michael Jordan traded in his high-tops for cleats, people had their doubts. What skills could this high-flying king of the court bring to the baseball diamond? Ask the players for the Birmingham Barons, the minor league team that he joined last year. Jordan didn't bring sophisticated baseball skills to the organization, but he was able to teach his new peers--all lifelong baseball players--about physical conditioning, competitiveness, mental preparation, and the ups and downs of fame. When materials managers from other industries sign on to a hospital team, there may be doubts about whether their skills are transferable. But, like Jordan, they bring to the team unique experiences and perspectives that can enhance the game. Hospitals that hire managers from other disciplines often find that these people bring bold new ideas to the organization. Their special skills could even help improve the performance of longtime players in the health care arena. We recently spoke with four hospital managers who immigrated to health care from other industries. Read their stories and you, too, might see your job in a whole new way.

Appropriate response to pneumococcal vaccine in celiac sprue

Hyposplenism as a complication of celiac sprue confers an increased risk of pneumococcal sepsis, but such patients do not routinely receive pneumococcal vaccine despite reports of overwhelming pneumococcal sepsis. Because antibody response in these patients has not been previously assessed, we measured pre- and postvaccination levels in 10 patients with documented sprue. All demonstrated appropriate acute antibody responses to a polyvalent pneumococcal vaccine. Vaccination of all patients with celiac sprue seems appropriate.

Crohn's disease and colorectal carcinoma: rectal cancer complicating longstanding active perianal disease

OBJECTIVES

Reports of Crohn's disease (CD)-associated colorectal carcinoma are being cited in the medical literature with increasing frequency. Our aim was to identify subgroups of patients with risk factors that may account for this.

METHODS

We reviewed the medical records of 16 patients with the simultaneous diagnosis of CD and colorectal carcinoma and, in addition, reviewed previously reported cases of CD-associated colorectal carcinoma.

RESULTS

Eight male and eight female patients presented with 18 carcinomas: four right colon, four transverse, two descending colon, and eight rectal lesions. Median age at presentation was 48 yr. The mean duration of CD before presentation of carcinoma was 19.7 yr. Two lesions were discovered in strictured bowel segments. Two patients had multiple cancers. One had simultaneous cecal and left colon adenocarcinomas. The other underwent resection of a right colon lesion and 5 yr later presented with transverse colon carcinoma. Eight patients had rectal cancer; all were diagnosed preoperatively. Six of these patients had a history of severe perianal CD. Six had undergone multiple incision and drainage procedures for perirectal abscesses and fistulas. Two developed malignancies in defunctionalized rectal stumps. One of these patients presented with simultaneous squamous rectal carcinoma and papillary bile duct cholangiocarcinoma.

CONCLUSIONS

Gastrointestinal malignancy in association with CD has been reported. Symptoms of chronic inflammatory disease may obscure clinical manifestations of occult malignancy and thereby delay diagnosis. Crohn's patients with long-standing anorectal or perianal disease and stricture may well warrant surveillance endoscopy and biopsy of involved areas with the hope of earlier detection and treatment of these rectal cancers.

DNA testing for fragile X syndrome in schools for learning difficulties

Fragile X syndrome is the most common inherited cause of mental retardation. Early diagnosis is important not only for appropriate management of individuals but also to identify carriers who are unaware of their high risk of having an affected child. The disorder is associated with a cytogenetically visible fragile site (FRAXA) at Xq27.3, caused by amplification of a (CGG)n repeat sequence within the gene at this locus designated FMR1. Clinical and molecular studies have been undertaken to screen for fragile X syndrome in 154 children with moderate and severe learning difficulties of previously unknown origin. Southern blot analysis of peripheral blood showed the characteristic abnormally large (CGG)n repeat sequence associated with fragile X syndrome in four of the 154 children. The findings were confirmed by cytogenetic observation of the fragile site and by further molecular studies. The families of the affected children were offered genetic counselling and DNA tests to determine their carrier status. These findings show that there are still unrecognised cases of fragile X syndrome. Given the difficulty of making a clinical diagnosis and the implications for families when the diagnosis is missed, screening in high risk populations may be justified. The issues involved in screening all children in special schools for fragile X syndrome are discussed.

Prospective analysis of colorectal carcinoma. Determination of an age-site and stage relationship and the correlation of DNA index with clinicopathologic parameters

PURPOSE

A prospective study of colorectal cancer (1987-1991) using flow cytometry was performed to determine the relationship of age with DNA index (DNA-I), sites of disease, Dukes stage, grade, and survival.

METHODS

The flow cytometry was performed on 138 fresh, unfixed, surgical specimens using 4',6'-diamidino-2-phenylindole, a DNA fluorochrome.

RESULTS

The mean age was 66.9 (42.8 percent > or = 70; range, 22-92; median, 68) years, and 48.6 percent were female. The patients' stages were (in percent): A, 4.4; B, 53.0; C, 38.2; D, 4.4. Tumor grades of differentiation (in percent) were well, 14.4; moderate, 68.9; poor, 16.7; and sites (in percent) were: rectum, 19.6; sigmoid/left, 50.7; transverse/right, 29.0. Aneuploidy (DNA-I not equal to 1.0; CV, 3.5 percent) was found in 58.8 percent. Age (by decade of presentation) was compared with site and Dukes stage. Older patients had more transverse/right-sided lesions (P = 0.003). Patients with Dukes C and D tumors had a lower age (by decade of presentation) than patients with B2 lesions (P = 0.03). Age was not related to DNA-I or grade or DNA-I with sex, grade, site, stage, or survival (P > 0.05).

CONCLUSIONS

This prospective study suggests that colorectal cancer tends to present at an earlier stage and in the more proximal colon in the older population. Because right-sided lesions are beyond the reach of sigmoidoscopy, these findings have prognostic and screening implications.