Residual catatonic state following neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is usually a self-limited disorder, with most cases resolving within 2 weeks after antipsychotic drug discontinuation. However, the course of NMS may not always be short-lived. In this report, the authors describe five patients who developed a residual catatonic state that persisted after acute hyperthermic symptoms of NMS had subsided and compare them with 27 similar cases in the literature. Two of our patients recovered gradually with supportive treatment. Three patients were treated with electroconvulsive therapy (ECT). Of these, two showed a positive response, although one died later of intercurrent pneumonia. A third patient did not respond to ECT, but recovered gradually thereafter. Although dopamine agonists or benzodiazepines have been advocated for the treatment of residual symptoms in previous case reports, ECT was the treatment most often associated with a rapid response and no mortality, even in patients refractory to pharmacotherapy. In conclusion, catatonic and parkinsonian symptoms of NMS may persist as a residual state lasting for weeks to months after more fulminant acute symptoms abate. These residual symptoms may be more likely to develop in patients with pre-existing structural brain disorders. Although patients may improve gradually with supportive care or pharmacotherapy, ECT can often be highly effective in treating the residual catatonic state that follows NMS.

Early pregnancy predictors of preterm birth: the role of a prolonged menstruation-conception interval

OBJECTIVE

To study early pregnancy characteristics as possible risk factors associated with preterm birth.

DESIGN

Retrospective analysis of prospectively collected maternity data.

POPULATION

21,069 singleton deliveries with record of a specified last menstrual period and a midtrimester dating scan.

SETTING

Catchment area of tertiary centre serving a general maternity population.

METHODS

Univariate and multivariate analysis. Variables included: maternal age; height; weight at first visit; parity; ethnic group; cigarette smoking and alcohol consumption recorded in early pregnancy; history of abortion; history of preterm birth; and discrepancy between menstrual dates and ultrasound dates.

MAIN OUTCOME MEASURES

Adjusted odds ratios for factors associated with preterm birth, stratified according to parity (nulliparae vs multiparae) and gestational age (early preterm, 24-33 weeks; late preterm, 34-36 weeks; all preterm, < 37 weeks). Population attributable risk (aetiologic fraction) of the significant variables for preterm birth.

RESULTS

The overall preterm (< 37 weeks) delivery rate according to scan dates was 7 x 0%. Preterm birth was associated with young (< 20 years), short (< or = 155 cm) and underweight (< or = 52 kg) mothers, non-Europeans, cigarette smokers, previous abortion or previous preterm delivery, and a prolonged menstruation-conception interval. Preterm births which followed the spontaneous onset of labour (72%) had results which were similar to the overall group, while there were too few iatrogenic preterm deliveries for separate analysis. Logistic regression showed that associations varied in different parity and gestational age groups. For nulliparae, smoking was not associated with preterm birth, but it was strongly associated with multiparous women (adjusted OR 1 x 8, 95% CI 1 x 6-2 x 1). A past history of premature delivery had the highest risk for birth before 34 weeks in the index pregnancy (adjusted OR 5 x 1, 95% CI 3 x 4-7 x 6). A discrepancy between menstrual and scan dates of greater than +7 days, suggestive of a prolonged interval between last menstruation and conception, was present in 23 x 3% of all pregnancies, and was associated with an increased risk of preterm delivery in all gestational age categories for nulliparae (adjusted OR 1 x 5, 95% CI 1 x 3-1 x 8) and multiparae (adjusted OR 1 x 9, 95% CI 1 x 6-2 x 2). Because of its high prevalence, this variable constituted a relatively high population-attributable risk for premature birth for both nulliparae (10 x 7%) and multiparae (16 x 6%).

CONCLUSIONS

A discrepancy of more than +7 days between menstrual and scan dates, indicating a prolonged interval between last menstruation and conception, is a significant predictor of preterm birth. This effect is independent of other factors such as maternal age, height, weight and smoking which are also associated with prematurity. In a maternity population with ultrasound scan dates and recorded last menstrual period, this variable can be easily calculated and used as a marker for increased surveillance.

Customized fetal weight limits for antenatal detection of fetal growth restriction

OBJECTIVE

To define cut-off limits for individually adjustable fetal weight standards for the detection of intrauterine growth restriction.

DESIGN

Retrospective study, with the outcome measures small-for-gestational age (SGA) birth weight, operative delivery for fetal distress, umbilical artery pH < 7.15, and admission to the neonatal intensive care unit.

SUBJECTS AND METHODS

Two hundred and fifteen women considered to be at increased risk of uteroplacental insufficiency were recruited to a study of serial ultrasound scans. Fetal weights were derived using standard formulae and, retrospectively, weight percentiles were calculated after individual adjustment for maternal height, weight in early pregnancy, ethnic group, parity and fetal sex.

INTRODUCTION

One or more antenatal scans indicative of fetal weight below the 10th customized percentile were predictive for a SGA neonate at birth (P < 0.001), operative delivery for fetal distress (P < 0.01) and admission to neonatal intensive care (P < 0.01) but not for a low umbilical artery pH (P = 0.6). Receiver-operator curves showed the optimal customized fetal weight percentile limit for predicting an SGA neonate to be the 18th percentile (sensitivity 83%, specificity 79%, positive predictive value 63% and negative predictive value 92%). For the prediction of operative delivery for fetal distress and admission to neonatal intensive care, the optional customized cut-off value was the 8th percentile.

CONCLUSIONS

The assessment of fetal weight using ultrasound and an individually-adjusted standard is predictive of growth restriction and perinatal events associated with hypoxia or diminished reserve. The optimal cut-off value for predicting operative delivery for fetal distress or admission to the neonatal intensive care unit suggests that the 10th customized percentile is a good limit for clinical use.

Catatonic signs in neuroleptic malignant syndrome

The study assessed catatonic signs in neuroleptic malignant syndrome (NMS). Records of inpatients meeting both stringent research criteria and DSM-IV criteria (n = 11) or only DSM-IV criteria (n = 5) for NMS were identified. The records were systematically rated on a 23-item rating scale for the presence of catatonic signs. Scores for NMS severity were related to the number of catatonic signs. Fifteen patients met both research criteria for catatonia and DSM-IV motor criteria for organic catatonia. The severity scores of NMS correlated with the number of catatonic signs (Spearman rho = +.71, P < .005). We conclude that multiple catatonic signs are present in NMS and the severity of NMS predicts the number of catatonic signs.

Respiratory diphtheria in three paediatric patients

From August till November 1998, the Paediatric and Anaesthetic Units of Hospital Kuala Terengganu managed three patients from Kuala Terengganu District who were ventilated for respiratory diphtheria. Their ages were 5, 4 and 7 years old and their immunisation for diphtheria were not complete. All three patients presented with respiratory distress and were ventilated for upper airway obstruction. Their treatment included intravenous penicillin and diphtheria antitoxin. One patient died of cardiogenic shock with secondary pneumonia. Pharyngeal and tonsillar swabs of all three patients grew toxigenic Corynebacterium diphtheriae biotype mitis. There were 765 throat cultures taken from contacts. The confirmed positive cultures grew 2 toxigenic and 3 non-toxigenic Corynebacterium diphtheriae biotype mitis and surprisingly, 10 non-toxigenic biotype gravis. A prevalence study is needed to document the endemicity of diphtheria in Kuala Terengganu and to determine the carrier rate of both biotypes. Steps have been taken to increase the immunisation coverage in children. The giving of regular booster doses of diphtheria toxoid to the adult population should be considered.

Over a decade of experience with a yeast recombinant hepatitis B vaccine

Experience with the yeast recombinant hepatitis B vaccine Engerix-B now exceeds 10 years. We reviewed published studies on this vaccine. These show the vaccine to be safe, causing mostly only minor local symptoms and to be highly immunogenic both in monitored clinical trials and under field conditions. Engerix-B consistently elicits high geometric mean antibody titres and a high protective efficacy has been established in three groups at high-risk of hepatitis B infection, homosexual men, institutionalised mentally handicapped subjects and neonates of chronic carrier mothers. The profile of the recombinant hepatitis B vaccine in certain high-risk groups and immuno compromised people is discussed. Finally we present updated post marketing surveillance data based on 496 million distributed doses of vaccine.

Neuregulins and ErbB receptors in cultured neonatal astrocytes

Neuregulins (NRGs) are a family of growth factors involved in signaling between neurons and glial cells of the peripheral and central nervous system. NRGs are synthesized and secreted by a number of cell types including Schwann cells, neurons, and oligodendrocytes. NRG transduction signals are mediated by the erbB family of receptor tyrosine kinases. These NRGs may be important for paracrine or autocrine signaling during development, injury, and the normal functioning of the central nervous system. In this study, we characterize the NRGs and erbB receptors expressed by cultured neonatal rat astrocytes. Using immunoblotting protocols with pan-specific antibodies, we identified eleven NRG molecular weight isoforms from approximately 16 kDa to 105 kDa in cultured neonatal rat astrocytes. Immunocyotchemistry with isoform-specific antibodies revealed the expression of both major isoform families (NRGalpha, NRGbeta). Additionally, astrocyte-conditioned media contained two molecular weight isoforms of NRGs. We detected mRNA expression of NRGalpha and NRGbeta in astrocytes by amplifying mRNA transcripts with reverse transcription polymerase chain reaction. Furthermore, we confirm that cultured astrocytes express all four erbB receptors as detected by immunocytochemical and immunoblotting techniques. These data indicate that astrocytes contain and secrete NRGs.

Amino acid substitutions reveal distinct functions of serine 186 of the ZEBRA protein in activation of early lytic cycle genes and synergy with the Epstein-Barr virus R transactivator

The ZEBRA protein mediates the switch between the latent and lytic life cycles of Epstein-Barr virus. Z(S186A), a point mutant in ZEBRA's basic domain in which serine 186 is changed to alanine, is unable to induce expression of lytic cycle mRNAs or proteins from the latent EBV genome even though it retains the ability to activate transcription from reporters bearing known ZEBRA-responsive promoters (A. L. Francis et al., J. Virol. 71:3054-3061, 1997). We now describe three distinct phenotypes of ZEBRA mutants bearing different amino acid substitutions at S186. These phenotypes are based on the capacity of the mutants to activate expression of the BRLF1 and BMRF1 genes, which are targets of ZEBRA's action, and to synergize with the BRLF1 gene product Rta (R transactivator) in activating expression of downstream genes. One mutant class, represented by Z(S186T), was similar to the wild type, although reduced in the capacity to activate BRLF1 and BMRF1 early lytic cycle genes from the latent virus. A second class, represented by Z(S186C) and Z(S186G), was impaired in transcriptional activation, unable to activate early lytic cycle products from the latent virus, and not rescued by overexpression of Rta. A third class, Z(S186A), although unable by itself to activate BRLF1 or other lytic cycle genes, synergized with Rta. Rta rescued the capacity of Z(S186A) to activate the BMRF1 early lytic cycle gene from the latent virus. All mutant classes bound to DNA in vitro, although their capacity to bind to different ZEBRA response elements varied. Serine 186 of ZEBRA is a critical residue that is required for the distinct activities of induction of BRLF1 expression and for synergy with Rta. Since only Z(S186T) among the mutants behaved similarly to the wild type, activation of BRLF1 likely requires phosphorylation of S186. However, since Z(S186A) could synergize with Rta, synergy with Rta does not appear to be dependent on phosphorylation of S186. S186 likely mediates DNA recognition on the BRLF1 promoter in the context of the latent virus, protein-protein interactions, or both. The Z(S186) mutants define the amino acid side chains required for these functions.

Controlled trial of fundal height measurement plotted on customised antenatal growth charts

OBJECTIVE

The purpose of this study was to evaluate the effect of a policy of standard antenatal care which included plotting fundal height measurements on customised antenatal charts in the community.

DESIGN

Prospective, non-randomised, controlled, population-based study.

POPULATION

Two defined and separate referral areas from community to teaching hospital, with similar delivery rates and socioeconomic characteristics. A total of 1272 consecutively booked women with singleton pregnancies and dating ultrasound scans before 22 weeks of gestation.

INTERVENTION

In the study area customised fundal height charts were issued to each mother at the routine hospital booking scan, on which regular fundal height measurements were to be plotted by community midwives. The charts adjusted limits according to maternal characteristics including height, weight, parity and ethnic group. Usual management in the control area included fundal height assessment by abdominal palpation and recording on a standard co-operation card.

OUTCOME MEASURES

Antenatal detection of small and large for gestational age babies; number of antenatal investigations for fetal growth in each group.

RESULTS

The study group had a significantly higher antenatal detection rate of small for gestational age babies (48% vs 29%, odds ratio 2.2, 95% confidence interval 1.1-4.5) and large for gestational age babies (46% vs 24%, OR 2.6, CI 1.3-5.5). There was no increase in the study group in the overall number of scans per pregnancy done in the ultrasound department (1.2 vs 1.3, P = 0.14), but a slight decrease in repeat (two or more) third trimester scans (OR 0.8, CI 0.6-1.0, P = 0.08). Women in the study group had significantly fewer referrals for investigation in a pregnancy assessment centre (OR 0.7, CI 0.5-0.9; P = 0.01) and fewer admissions to the antenatal ward (OR 0.6, CI 0.4-0.7, P < 0.001). There were no differences in perinatal outcome.

CONCLUSIONS

Serial measurement of fundal height plotted on customised charts leads to increased antenatal detection of small and large babies. This is accompanied by fewer investigations, which is likely to represent increased confidence in the community to recognise normal fetal growth. With adjustments for physiological variables, fundal height measurements appear to be a cost effective screening method which can result in substantial improvements in the antenatal assessment of fetal growth.

Fetal growth rate and adverse perinatal events

OBJECTIVE

To study fetal weight gain and its association with adverse perinatal events in a serially scanned high-risk population.

SUBJECTS AND METHODS

A total of 200 pregnant women considered at increased risk of uteroplacental insufficiency had a total of 1140 scans in the third trimester, with a median of six scans in each pregnancy. The average fetal growth rate was retrospectively calculated for the last 6 weeks to birth, and expressed as daily weight gain in grams per day. Adverse pregnancy outcome was defined as operative delivery for fetal distress, acidotic umbilical artery pH (< 7.15), or admission to the neonatal intensive care unit (NICU).

RESULTS

Fetuses with normal outcome in this high-risk pregnancy population had an average antenatal growth rate of 24.2 g/day. Compared to pregnancies with normal outcome, the growth rate was slower in those that required operative delivery for fetal distress (20.9 g/day, p < 0.05) and those that required admission to the NICU (20.3 g/day, p < 0.05). The growth rate in pregnancies resulting in acidotic umbilical artery pH also seemed lower, but this did not reach statistical significance.

CONCLUSIONS

Impaired fetal weight gain prior to birth is associated with adverse perinatal events suggestive of growth failure.

Hereditary breast cancer

Popliteal vein reflux reduces the healing of chronic venous ulcer

S. G. Darke, Vascular Surgery Department, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK

Predicting changes in the distribution of sweating following thoracoscopic sympathectomy

J. Collin, Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK

Author's reply J. A. Rennie, Academic Department of Surgery, King's College Hospital, Denmark Hill, London SE5 9RS, UK

Hereditary breast cancer

G. J. Hicken, A. Francis, S. A. Harries, Department of Surgery, Warwick Hospital, Lakin Road, Warwick CV34 5BW, UK

Laparoscopy for the impalpable testis

P. F. Jones, G. G. Youngson, Department of Surgery, Royal Aberdeen Children's Hospital, Cornhill Road, Aberdeen AB9 2ZG, UK

Helicobacter pylori and peptic ulcer surgery

I. L. P. Beales, Department of Gastroenterology, West Norwich Hospital, Bowthorpe Road, Norwich NR2 3TU, UK

Early effect of carotid endarterectomy on arterial blood pressure measured with an ambulatory monitor

S. L. Drinkwater, G. Stansby, H. H. G. Eastcott, Department of Surgery, St Mary's Hospital, Praed Street, London W2 1NY, UK

Author's reply S. R. Dodds, A. D. B. Chant, Department of Surgery, E Level, West Wing, Southampton General Hospital, Tremona Road, Southampton SO16 9YD, UK

Neuregulins in glial cells

The role of growth factors in controlling the development of glial cells in both the peripheral and central nervous systems has been investigated for a number of years. The recent discovery of a new family of growth factors termed the neuregulins (NRGs) has led to an explosion of information concerning the putative role of these growth factors in the development of Schwann cells (SC), oligodendrocytes (OLG), and astrocytes. Many of these previous studies have focused on the effects of exogenous NRGs on glial cell development and differentiation. We now review the evidence that these glial cells themselves produce NRGs and discuss the major implications of these findings with respect to glial cell development and diseases which affect glial cell function. We also discuss the potential role of endogenous NRGs following neural injury.

Tissues of MSH2-deficient mice demonstrate hypermutability on exposure to a DNA methylating agent

The mutational response of mismatch repair-deficient animals to the alkylating agent N-methyl-N-nitrosourea was evaluated by using a transgenic lacI reporter system. Although the mutations detected in MSH2 heterozygotes were similar to those of controls, MSH2-/- animals demonstrated striking increases in mutation frequency in response to this agent. G:C to A:T transitions at GpG sites, as opposed to CpG sites, dominated the mutational spectrum of both MSH2+/+ and MSH2-/- N-methyl-N-nitrosourea -treated animals. Extrapolating to humans with hereditary non-polyposis colorectal cancer, the results suggest that MSH2 heterozygotes are unlikely to be at increased risk of mutation, even when exposed to potent DNA methylating agents. In contrast, mismatch repair-deficient cells spontaneously arising within individuals with hereditary non-polyposis colorectal cancer would likely exhibit hypermutability in response to such mutagens, an outcome predicted to accelerate the pace of tumorigenesis.

Fetal weight gain in a serially scanned high-risk population

Physiological as well as pathological variables influence fetal growth. This study was undertaken to assess the influence of physiological variables on fetal weight gain in a high-risk population with normal outcome. A total of 121 pregnancies had 3-13 (median 8) ultrasound scans in the third trimester. Estimated fetal weight was calculated according to standard formulae. The estimated fetal weight at 30, 34 and 38 weeks and growth per day in the last 2 weeks prior to delivery were calculated and compared between subgroups defined on physiological characteristics, such as maternal height, maternal weight, parity and fetal sex. There were differences in growth curves for each of the physiological parameters studied. Maternal height and weight were significantly related to the estimated fetal weight throughout the third trimester but there were no significant differences in growth per day in the last 2 weeks before birth. In contrast, subgroups defined by parity and fetal sex did not show significant fetal weight differences in the third trimester, but the daily growth rate prior to birth was significantly higher for multiparae and male fetuses. Physiological factors affect fetal weight gain and need to be taken into account when fetal growth is monitored in high-risk pregnancies.

Catatonia and other motor syndromes in a chronically hospitalized psychiatric population

BACKGROUND

To determine the motor characteristics of chronic catatonia, catatonia and other motor disorders were systematically rated in a long-term hospitalized sample.

METHOD

Chronically hospitalized psychiatric inpatients (N = 42) with a clinical diagnosis of catatonic schizophrenia (295.2X) were rated for catatonia with a novel 23-item catatonia rating scale, and for parkinsonism, dyskinesia and akathisia using standard rating scales with scale-based criteria for case definition.

RESULTS

Catatonia was the sole motor syndrome in nine cases (21%), co-existed with parkinsonism in five (12%), tardive dyskinesia in four (10%), and both parkinsonism and tardive dyskinesia in 10 (24%). There was no correlation between total scores across the four rating scales. 'Rigidity' was the sole catatonic sign which overlapped with other scales. The symptom profile of catatonia in this chronic sample was similar to previous reports based on acutely ill patients.

CONCLUSION

Catatonia is distinguishable from other motor disorders in chronic psychiatric patients using the 23-item catatonia rating scale. The features of chronic catatonia are described, and the distribution of catatonic signs is similar for chronic and acute catatonia.

Synergism of lorazepam and electroconvulsive therapy in the treatment of catatonia

Electroconvulsive therapy (ECT) and lorazepam are effective treatments for catatonia. ECT combined with benzodiazepines has been associated with reduced efficacy and efficiency and therefore is not recommended in the routine practice of ECT. We report 5 prospectively identified cases of catatonia treated either sequentially or concurrently with lorazepam and ECT. In each case, the combination of lorazepam with ECT was superior to monotherapy. This apparent synergism, its possible mechanisms, and its implications for treating catatonia are discussed.

Base transitions dominate the mutational spectrum of a transgenic reporter gene in MSH2 deficient mice

Tumors derived from individuals with hereditary nonpolyposis colorectal cancer syndrome frequently demonstrate mutations in both alleles of hMSH2, a key gene in DNA mismatch repair (MMR). Sporadic tumors also frequently exhibit MMR deficiency. In keeping with the role of MMR in the maintenance of genome integrity, mice deficient in MSH2 via gene targeting demonstrate a high incidence of thymic lymphomas and small intestinal adenocarcinomas. To investigate the effects of MSH2 deficiency in normal tissues, mice containing a retrievable transgenic lacI reporter gene for mutation detection were crossed with MSH2-/- mice. Mice homozygous for MSH2 deficiency revealed 4.8, 11.0 and 15.2-fold elevations in spontaneous mutation frequency in DNA obtained from brain, small intestine, and thymus, respectively, as compared to heterozygous or wild-type mice. Mutations most frequently recovered from MSH2-/- mice were single base substitutions (77%), particularly base transitions (64%). Frameshifts occurred less frequently (19%) and fell within very short (3-5 bp) mononucleotide runs. Thus the number of key growth control genes potentially impacted by MMR deficiency extends beyond those containing repetitive sequences. These results highlight the capacity for MSH2 deficiency to serve as a potent driving force during the multi-step evolution of tumors.

Gestational age and induction of labour for prolonged pregnancy

OBJECTIVE

To examine the length of gestation according to menstrual and ultrasound scan dates, and the rate of induction of labour in a unit with a routine induction policy for prolonged pregnancy.

DESIGN

Retrospective analysis of computer files of 24,675 pregnancies delivered in a teaching hospital between 1988 and 1995, which had a record of the last menstrual period and a dating ultrasound scan. Detailed survey of 168 casenotes of consecutive inductions of labour to establish the indications given.

SETTING

Teaching hospital with policies of routine mid-trimester ultrasound scan and routine induction for prolonged pregnancy at 290 to 294 days.

MAIN OUTCOME MEASURES

Gestational age at delivery by menstrual history and ultrasound biometry in spontaneous and induced labours.

RESULTS

The single largest category of reasons given for induction of labour was prolonged pregnancy. 'Post-term pregnancy', from the date of expected delivery as recorded in the notes, together with 'maternal request' and 'social factors', were the reasons given for induction of labour in 71.3% of cases. Menstrual dates systematically overestimated gestational age at term when compared with scan dates. After 41 weeks, this difference exceeded the confidence limits for second trimester scan dating error, suggesting that most pregnancies which are considered 'prolonged' according to menstrual dates are in fact mis-dated. The median gestational age for induced labours was 286 days by last menstrual period but only 280 days by scan, and most (71.5%) inductions done post-term (> 294 days) according to menstrual dates were not post-term if scan dates alone are used to calculate the gestational age. The average induction rate over the seven year study period was 16.6%. It was higher when there was any gestational age error in either direction (16.8%) compared with when menstrual and scan dates were in complete agreement (13.7%, OR 1.27, CI 1.09-1.47, P < 0.001). The induction rate was highest (up to 21.8%) in the cases where menstrual dates overstated gestational age without exceeding the usual limits for adjusting dates according to scan. Such overestimation within tolerance limits of 7, 10 or 14 days occurred in 37.1%, 45.8%, or 52.6% of all pregnancies, respectively.

CONCLUSIONS

Most pregnancies undergoing post-term induction are not post-term when assessed by ultrasound dates. Regardless of whether prolonged pregnancy is considered to be a risk factor requiring intervention, the proportion of pregnancies considered 'post-term' can be reduced considerably by a dating policy which ignores menstrual dates and establishes the expected delivery date on the basis of ultrasound dates alone.