Fatal toxicity of antidepressants in England and Wales, 1993-2002

This article examines trends in drug poisoning deaths involving antidepressant drugs between 1993 and 2002 in England and Wales as a whole and focuses particularly on the relationship between antidepressant prescribing and deaths in England. Between 1993 and 2002, age-standardised mortality rates in England and Wales decreased from about 9 to 7 per million population for both males and females. However, unlike females, rates in males rose to a peak of 12 per million in 1997 before declining. During the study period, the number of prescription items for antidepressants increased two and a half fold, largely due to increased use of selective serotonin re-uptake inhibitors and other antidepressants. Overall, death rates in England, per million prescription items, declined over the study period, with reductions in the rates for Dothiepin, Amitriptyline and all tricyclic antidepressants. There was no change in the rate for selective serotonin re-uptake inhibitors while rates for other antidepressants increased. Despite these trends, through all the study period rates were highest for tricyclic antidepressants and lowest for selective serotonin re-uptake inhibitors.

A comparison of two methods of labor induction with vaginal misoprostol

OBJECTIVES

To evaluate if labor induction with 50 microg of vaginal misoprostol twice per day is as effective as and safer than 100 microg used once per day.

METHODS

Misoprostol was used to induce labor in 204 consecutive pregnant women assessed as needing labor induction, 104 at the University Hospital of the West Indies in Kingston, Jamaica, and 100 at the Victoria Jubilee Hospital, also in Kingston. At the former institution the women were administered 100 microg of misoprostol once per 24 h and at the latter 50 microg every 12 h. The doses were repeated if there was no cervical change or if the woman was not in labor. Bishop scores were determined before initiation of induction and again 12 h later. Women's records were reviewed after 24 h to determine delivery outcome.

RESULTS

The indications for labor induction were similar in each group. There was no significant difference in the group demographics. In the group given 50 microg of misoprostol twice per day the mean time+/-S.D. from insertion of misoprostol to delivery was significantly shorter than in the other group (560.14+/-269.20 min vs. 729.90+/-471.65 min; P<0.01), and the percentage of women who were delivered within 12 h was higher (75% vs. 56.8%; P<0.002). There was no significant difference between the two groups in the rate of cesarean births, the need for oxytocin, or blood loss. Only two patients experienced uterine hyperstimulation, both in the group that had received 100 microg of misoprostol per day. There was no significant difference between the two groups in the birthweight of the neonates and in the number of neonates with Apgar scores less than 7 at 1 min and 5 min. There were, however, significantly fewer neonates who needed resuscitation (6% vs. 14.7%; P=0.04) and admission to the special care nursery (7% vs. 17%; P=0.03) in the group that had received 50 microg of misoprostol twice per day.

CONCLUSIONS

A dose of 50 microg of misoprostol twice per day appears to be more efficient and safer than a dose of 100 microg once per day, but this may partially be due to weaknesses in the study design.

HLA-DRB3*0101 is associated with Graves' disease in Jamaicans

OBJECTIVES

Graves' disease is associated with different human leucocyte antigen (HLA) genes in different populations. This studywasdesigned to examinethe HLA class II associations with Graves' disease in Jamaicans.

PATIENTS

One hundred and six Jamaicans with Graves' disease and 104 controls.

DESIGN

Oligotyping for HLA-DRB1, DRB3, DQA1 and DQB1 alleles was performed using the polymerase chain reaction sequence specific oligonucleotide probe (PCR-SSOP) technique. RESULTS The frequency of HLA-DRB3 *0101 was increased significantly in the patients compared to controls (38.7% vs. 19.2%; RR = 2.72; Pc < 0.015). The protective alleles for Graves' disease were DRB1 *0901 (0.9% vs. 20.2%; RR = 0.04; Pc < 0.001), DRB1*1001 (0.0% vs. 11%; RR = 0.0%; Pc < 0.01) and DRB4 *0101 (0.0% vs. 12.5%; RR = 0.0; Pc < 0.05). A high female to male ratio of Graves' disease, 25 :1, was observed. Other associated autoimmune diseases were rare and no significant HLA class II associations were found with clinical markers of disease.

CONCLUSIONS

Jamaican patients with Graves' disease share the DRB3 *0101 susceptible allele and the DRB4 *01 protective allele but not the susceptible haplotype DRB1 *0301, DRB3*0101, DQA1*0501 with Caucasians.

Policy implications for implementing evidence-based practices

The authors describe the policy and administrative-practice implications of implementing evidence-based services, particularly in public-sector settings. They review the observations of the contributors to the evidence-based practices series published throughout 2001 in Psychiatric Services. Quality and accountability have become the watchwords of health and mental health services; evidence-based practices are a means to both ends. If the objective of accountable, high-quality services is to be achieved by implementing evidence-based practices, the right incentives must be put in place, and systemic barriers must be overcome. The authors use the framework from the U.S. Surgeon General's 1999 report on mental health to describe eight courses of action for addressing the gap between science and practice: continue to build the science base; overcome stigma; improve public awareness of effective treatments; ensure the supply of mental health services and providers; ensure delivery of state-of-the-art treatments; tailor treatment to age, sex, race, and culture; facilitate entry into treatment; and reduce financial barriers to treatment.

HTLV-1 associated polymyositis in Jamaica

The clinical, laboratory and epidemiological characteristics of 38 adult Jamaican patients with polymyositis were evaluated. Twenty-four patients (63%) were human T-lymphotropic virus 1 (HTLV-1) seropositive and 14 patients (37%) were HTLV-1 seronegative. Polymyositis runs a more protracted course in seropositive patients who had more frequent hospital admissions and a significantly longer duration of symptoms prior to presentation. Joint swelling, chest pain and dyspnoea were more frequent complaints among the seronegative patients. There was no significant difference between the two serological groups in muscle enzyme levels, antinuclear antibody positivity or frequency of Jo-1 antibodies. HTLV-1 infection may define a subgroup of polymyositis patients with a more insidious presentation and poorer response to corticosteroid therapy.

Team nursing and ITU--a good combination?

Deficits in 'measurable care', in an 11-bedded intensive care unit, prompted a pilot study of team nursing. Team nursing was introduced for three beds out of the total 11 for a period of six months. In order to evaluate the effects, aspects of care and job satisfaction were measured and compared between the team nursing beds and the rest of the unit. The study revealed that job satisfaction and the levels of 'measurable care' did not improve whilst team nursing was practised. Based on this evidence, the authors question the relevance of team nursing in this particular intensive therapy unit (ITU) and maintain that the best method of delivering nursing care in ITU remains unclear.

Community screening interview for dementia (CSI 'D'); performance in five disparate study sites

The Community Screening Interview for Dementia (CSI 'D') was developed as a screening instrument for dementia for use in cross-cultural studies. It consists of two components, a cognitive test for non-literate and literate populations and an informant interview regarding performance in everyday living. The development of the CSI 'D', involving harmonization, translation, back translation and pilot testing, for use in five sites is described. The results demonstrate the adaptability and utility of the CSI 'D' in populations from very different socioeconomic backgrounds. The inclusion of informant data adds significantly to the performance of the CSI 'D' as a dementia screen. The combination of informant and cognitive scores in a discriminant score produces better sensitivity and specificity for dementia than cognitive scores alone. The informant score has a significant independent effect in predicting dementia.

Direct analysis of viral-specific CD8+ T cells with soluble HLA-A2/Tax11-19 tetramer complexes in patients with human T cell lymphotropic virus-associated myelopathy

Human T cell lymphotropic virus-I (HTLV-I)-associated myelopathy is a slowly progressive neurologic disease characterized by inflammatory infiltrates in the central nervous system accompanied by clonal expansion of HTLV-I-reactive CD8+ T-cells. In patients carrying the HLA-A2 allele, the immune response is primarily directed to the Tax11-19 peptide. The frequency, activation state, and TCR usage of HLA-A2/Tax11-19 binding T cells in patients with HTLV-I-associated myelopathy was determined using MHC class I tetramers loaded with the Tax11-19 peptide. Circulating Tax11-19-reactive T cells were found at very high frequencies, approaching 1:10 circulating CD8+ T cells. T cells binding HLA-A2/Tax11-19 consisted of heterogeneous populations expressing different chemokine receptors and the IL-2R beta-chain but not the IL-2R alpha-chain. Additionally, Tax11-19-reactive CD8+ T cells used one predominant TCR Vbeta-chain for the recognition of the HLA-A2/Tax11-19 complex. These data provide direct evidence for high frequencies of circulating Tax11-19-reactive CD8+ T cells in patients with HTLV-I-associated myelopathy.

A study of the efficacy of felodipine given once or twice daily in the management of elderly hypertensive patients

The use of medication given once daily in clinical practice may lead to inadequate control of blood pressure (BP) over 24 h because medication is frequently titrated at the time of peak effect. Twenty-three patients aged 65-84 completed a study in which they received placebo, felodipine 2.5 mg once daily, felodipine 2.5 mg 12-hourly, and felodipine 5 mg once daily in a randomized, double-blind crossover design. BP response was assessed in the clinic 24 h after medication and by 24 h ambulatory monitoring. The trough/peak ratio was defined as the fall in BP in the 23rd and 24th hour post dose divided by the fall in BP in the 3rd and 4th hour post dose. BP fell with all three regimes and the clinic BPs did not differ from each other but were lower than placebo. Peak BP responses from the ambulatory BP monitor recording were similar with each dose but a greater percentage of the effect was maintained prior to the morning dose with 2.5 mg 12 hourly and 5 mg once daily. Felodipine 2.5 mg once daily reduces BP and in some people this effect persists for 24 h. However if this dose is used BP should be measured prior to the dose of the drug to ensure that 24 h control is maintained. Felodipine 5 mg once daily and felodipine 2.5 mg b.d. were equally effective at maintaining control and there was no significant advantage in using the twice daily regime. If felodipine 5 mg once daily or higher doses are used BP can be titrated post dose with the knowledge that more than 75% of the effect will still be present prior to the next dose of the drug. Thus once daily felodipine extended release (ER) 5 mg or more can be used effectively to maintain BP control over 24 h in clinical practice. In some elderly patients felodipine ER 2.5 mg once daily is an adequate regime.

Effect of dose on trough peak ratio of antihypertensive drugs in elderly hypertensive males

1. The study was undertaken in male patients aged 61-73 years with essential hypertension. 2. The patients had previously had their blood pressure controlled with the drug studied. 3. A randomized crossover study compared the effect of different drug doses on peak (3 h) and trough (24 h) blood pressure compared to placebo. 4. All drug doses used lowered blood pressure at peak response and the responses with different doses of angiotensin converting enzyme inhibitors were similar. The peak response to felodipine had some dose dependency. 5. Trough blood pressure was not different from placebo with enalapril, 5 and 10 mg, perindopril, 2 mg, felodipine, 2.5 mg but was different with enalapril, 20 and 40 mg, perindopril, 4 and 8 mg and felodipine, 5 and 10 mg. 6. Trough peak ratio was dose dependent, with the greatest dependency seen with enalapril which has the shortest half-life. 7. When low doses of enalapril (5 or 10 mg), perindopril (2 mg) or felodipine ER (2.5 mg) are used it is important to check blood pressure prior to the next dose to ensure that control is achieved and maintained.

Effectiveness of blood pressure control with once daily administration of enalapril and perindopril

Ten patients who had their blood pressure controlled with enalapril (10 mg, n = 4; 20 mg, n = 6) and 10 control subjects on perindopril (4 mg, n = 6; 8 mg, n = 4) entered a double-blind crossover study. They received placebo or the active drug 1 week apart and had their blood pressure measured at 0, 2, 3, 4, and 24 h. Then they crossed over to the other angiotensin-converting enzyme inhibitors (4 mg perindopril congruent to 10 mg enalapril) and the double-blind study was repeated. Blood pressure control 2 to 4 h after drug administration was similar with both drugs (perindopril = 150 +/- 2/80 +/- 1; enalapril = 150 +/- 2/81 +/- 1). Twenty-four h after administration of perindopril blood pressure was lower than on enalapril (perindopril = 154 +/- 3/85 +/- 2; enalapril = 159 +/- 3/89 +/- 2). Enalapril, 2 to 4 h after administration, caused a greater decrease than placebo, whereas the change with perindopril did not differ from placebo. Twenty-four hours after receiving the active drug the blood pressure of subjects on perindopril did not differ from the peak effect when corrected for placebo and circadian variation, whereas the blood pressure on enalapril was higher. This study indicates that perindopril in the doses used has a longer duration of action than enalapril and is more suited to once daily use.

Transactivation of interleukin 2 and its receptor induces immune activation in human T-cell lymphotropic virus type I-associated myelopathy: pathogenic implications and a rationale for immunotherapy

A state of T-cell activation, reflected by a marked degree of spontaneous proliferation in vitro, exists among patients with human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) but not in those with retroviral-induced adult T-cell leukemia (ATL). We wished to define the mechanism by which the immune activation of circulating cells from HAM/TSP is driven, thus gaining insight into the pathogenesis of this HTLV-I-associated disease. By using a modification of the polymerase chain reaction, we compared the levels of interleukin 2 (IL-2) and IL-2 receptor alpha chain (IL-2R alpha) mRNA expression to the transcription of the HTLV-I transactivator gene, pX, in peripheral blood mononuclear cells of HAM/TSP and ATL patients as well as seropositive carriers. Up-regulation of IL-2 and IL-2R alpha transcripts was detected in HAM/TSP and seropositive carriers that paralleled the coordinate mRNA expression of the pX transactivator. In addition, IL-2 and soluble IL-2R alpha serum levels in HAM/TSP and seropositive carriers were elevated. Despite markedly elevated levels of soluble IL-2R alpha in ATL, transcripts for IL-2 and pX were not demonstrable in the circulating cells. Finally, the marked degree of in vitro spontaneous proliferation present in HAM/TSP was profoundly inhibited by specific anti-IL-2R or anti-IL-2 blocking antibodies. Collectively, these results suggest that immune activation in HAM/TSP, in contrast to ATL, is virally driven by the transactivation and coordinate expression of IL-2 and IL-2R alpha. This deregulated autocrine process may contribute to the evolution of inflammatory nervous system damage in HAM/TSP.

Jamaican neuropathy: an electrophysiological study

Jamaican neuropathy (JN) is a common disorder in Jamaica and has characteristics similar to neurological diseases found in other tropical areas. JN is a clinical syndrome and occurs in two forms: spastic and ataxic. This is the first known electrophysiological study of this disease. In the spastic group of JN, peripheral electrophysiological findings were mostly normal, suggesting a central cause for their symptoms. The only patient with the ataxic form of JN had a chronic axonal peripheral neuropathy.

Intestinal perforation in ascariasis--case reports

Two cases of intestinal perforation in association with ascariasis are described. In both cases adult ascarids were found either in the gut or lying free in the peritoneal cavity. Neither patient had typhoid fever, one had Hodgkin's lymphoma. The authors believe that the perforation were directly caused by the ascarids. Both patients died.