Serum lipid profiles in major depression with clinical subtypes, suicide attempts and episodes

BACKGROUND

We tried to report the data between serum lipid profiles and major depression with different clinical subtypes, with or without suicide attempts, and with single episode or recurrent episodes.

METHOD

During a 2-year period, a total of 168 participants (109 patients with major depression and 59 subjects in a healthy control group) were recruited in this study. Blood samples for serum lipid profiles in all participants were collected. Data analysis was performed by using an analysis of covariance (ANCOVA) with body mass index (BMI) adjustment.

RESULTS

The data showed that there were no significant differences of any kind in serum lipid profiles between depressive patients with melancholic feature or atypical feature, with or without suicide attempts nor between depressive patients with single episode or recurrent episodes.

CONCLUSION

The results suggested there were no serum lipid profiles used as biological markers to distinguish the clinical subtypes, suicide attempts and episodes in patients with major depression.

The Significance of Hepatic Vein Outflow Volume in Hepatic Outflow Insufficiency of Living Right Liver Graft Evaluated by Doppler Ultrasound

The color Doppler ultrasound has been used to evaluate hepatic vein (HV) outflow insufficiency based on flow velocity and waveforms. In our experience, some cases with flat waveforms are clinically asymptomatic. The parameters of HV flow velocity and waveforms are not always correlated with clinical problems. So, we proposed that total HV flow volume (HVFV) may be a more reliable index. From August 2001 to July 2003, 31 cases among 48 adult-to-adult living related transplants of a right liver graft had one HV anastomosis. HV velocity, waveforms, and HVFV were compared both before and after transplantation. We set the minimal HVFV ratio at 80% based on the original HVFV before graft retrieval. There was no significant difference in HVFV before liver graft retrieval between the 2 groups, but there was a significant change after transplantation. There were no cases of HV insufficiency among group A patients (>80%), whose HVFV ranged from 397 to 1181 mL/min with ratios from 75% to 180% (mean 115%). In group B, there were 4 complicated cases with prolonged severe ascites (<80%) with HVFV ratios from 56% to 76% (mean 66%). Fisher exact test showed a great significance (P < .001). Thus the preliminary criteria of 80% minimal HVFV ratio allows detection of HV insufficiency for further interventional management.

Lorazepam and diazepam rapidly relieve catatonic signs in patients with schizophrenia

The uses of lorazepam and electroconvulsive therapy (ECT) have been proven to be effective in treating catatonia. In the present study a modified treatment strategy (i.e. lorazepam i.m. injection or diazepam infused i.v. if lorazepam failed, not with ECT) was proposed to rapidly relieve catatonic signs in patients with schizophrenia. During a 3-year period, 14 patients with catatonic schizophrenia in Chinese ethnic background Taiwanese were brought to the emergency unit of a general hospital. First, the patients were immediately treated with lorazepam 1 or 2 ampules (2 mg/mL per ampule) i.m. injection (IMI) during 2 h. Second, if the previous 2 ampules of lorazepam IMI failed, diazepam infused i.v. (10 mg/2 mL per ampule) in normal saline 500 mL every 8 h would be done during 1 day. The response rate of catatonic signs in these 14 patients with lorazepam IMI during the first 2 h was 85.7% (12/14). However, according to the results of this method, the total response rate to benzodiazepines during 1 day was 100%(14/14). These results suggested that this modified treatment strategy could rapidly and completely relieve catatonic signs, even without the use of ECT.

Hepatic venous stenosis in partial liver graft transplantation detected by color Doppler ultrasound before and after radiological interventional management

Hepatic outflow insufficiency remains one of the major complications causing postoperative graft failure especially among partial liver graft transplantations (PLT) including living donor liver transplantation (LDLT), reduced size liver transplantation (RLT), and split liver transplantation (SLT). These procedures are different from the whole liver graft transplantations (OLT), which include multiple vascular anastomoses. Color Doppler ultrasound (CDUS) was used to evaluate the hepatic venous outflow from grafts before and after radiological interventional management and to document treatment effects. From June 1994 to March 2003, our 136 cases of PLTs included 131 LDLTs, two RLTs, and three SLTs. Seven cases (six children and one adult) showed postoperative hepatic vein outflow obstruction and persistent massive ascites, as detected by color Doppler ultrasound (CDUS) and confirmed by interventional angiography. The CDUS showed a monophasic flat waveform with a relatively low hepatic vein average peak velocity (Va) in all cases (mean 11 cm/s). Successful interventional procedures included balloon dilatation in three cases and metallic stent replacement in four cases. CDUS was used with guidance during the procedure to confirm restoration of normal hepatic vein flow with a multiphasic waveform and an objective increase of average flow velocity (high to average 66 cm/s). Ascites disappeared dramatically after the procedure. In conclusion CDUS is the prime modality to diagnose and document a treatment response.

The significance of transarterial embolization for advanced hepatocellular carcinoma in liver transplantation

INTRODUCTION

Transarterial embolization (TAE) is the treatment of choice for advanced HCC to control or even induce tumor shrinkage. The aim of this study was to evaluate the effect of pretransplantation TAE for treatment of advanced HCC.

MATERIAL AND METHODS

From 1996 to 2002, we studied 12 cirrhotic patients with HCC, including six who met and six who exceeded the Milan criteria. All patients had sufficient hepatic function to undergo TAE. Liver transplantations were performed subsequently and they were followed prospectively for a median of 22 months (range = 12 to 53 months).

RESULTS

The explanted livers from the 12 patients who had undergone TAE were noted to have extensive tumor necrosis. The pathological specimens at LT showed downstaging of the HCC, which allowed those six patients to meet the Milan criteria. The overall 1- and 2-year survival rates were 92% and 73%, respectively. The overall 1- and 2-year disease-free survival rates were 92% and 73%, respectively. One death unrelated to liver disease at 2 years after LT was noted in the downgraded group. One patient of the initially eligible group developed lung metastasis at 6 months and died at 12 months after LT.

CONCLUSION

TAE is effective to downstage advanced HCC and reduce the dropout rate on the LT waiting list. Pre-LT TAE may be considered as a better therapeutic strategy for patients with advanced HCC.

Massive pulmonary embolism in a young patient on clozapine therapy

Clozapine-associated induction of venous thromboembolism has potentially catastrophic consequences. We report a case of sudden death caused by bilateral main pulmonary trunk thrombosis in a 31-year-old man receiving clozapine therapy. The patient presented with general weakness and exertional dyspnea. Bilateral main pulmonary trunk thrombosis was clearly demonstrated by helical chest computed tomography.

Lipid and lipoprotein levels in depressive disorders with melancholic feature or atypical feature and dysthymia

The purpose of the present study was to explore the relationship between serum lipid and lipoprotein levels and clinical subtypes in patients with depressive disorders. A total of 207 patients who were admitted for general health screening were assessed by using the semistructured clinical interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria for the possibility of having depressive disorders. Blood and physical examinations were done to rule out systemic diseases. A total of 142 patients without systemic diseases was recruited for further analysis, including dysthymia (n = 35), major depressive disorder with melancholic feature (n = 22), major depressive disorder with atypical feature (n = 46) and normal controls (n = 39). Analysis of covariance after age adjustment reveals significant differences in patients with melancholic feature and patients with atypical feature in serum concentrations of triglyceride (TG) and very-low-density-lipoprotein cholesterol (VLDL) in men, and high-density-lipoprotein cholesterol (HDL) in women. This suggests that the TG, VLDL and HDL levels might be used as biological markers to differentiate between major depressive patients with melancholic feature or atypical feature.

Bilateral adrenocortical adenomas causing ACTH-independent Cushing's syndrome at different periods: a case report and discussion of corticosteroid replacement therapy following bilateral adrenalectomy

We report a rare case of bilateral adrenocortical adenomas causing ACTH-independent Cushing's syndrome at different periods 9 yr apart. The subject, a 24-yr-old woman, in June 1989 had a typical Cushingoid appearance. Her baseline plasma cortisol levels did not show a diurnal rhythm and she had a very low baseline plasma ACTH level. Plasma cortisol levels could not be suppressed by overnight low-dose or two-day high-dose dexamethasone suppression test. Marked uptake of 131I-6beta-iodomethyl-19-norcholesterol (NP-59) was observed in the right adrenal gland. Abdominal computed tomography (CT) showed a right adrenal tumor. The right adrenal gland with adenoma was removed. The non-tumorous part of the adrenal cortex was atrophic. By April 1998, she had experienced a weight gain of more than 20 kg over a two-yr period. The baseline plasma cortisol levels were at the lower limit of the normal range with loss of diurnal rhythmicity. The baseline plasma ACTH levels were very low. Neither a two-day low-dose nor a two-day high-dose dexamethasone suppression test could suppress serum cortisol or urinary free cortisol levels. NP-59 adrenal scan revealed increased uptake of the left adrenal gland at 72 h after intravenous injection of the tracer. Abdominal CT and magnetic resonance imaging (MRI) all demonstrated a left adrenal mass. Left adrenalectomy was performed in June 1998; histological features showed a cortical adenoma and atrophic change in the non-tumorous part of the adrenal cortex. Elevated plasma ACTH levels after bilateral adrenalectomy could be suppressed with conventional corticosteroid replacement therapy and overnight low-dose dexamethasone suppression test.

Pessimistic mood in decompensated narcissistic patient

We report the negative emotional state as pessimistic mood of a case with narcissistic personality disorder during the period of narcissistic decompensation. In addition, we identified the clinical differences between pessimistic mood and depressive disorder. An 28-year-old unmarried woman experienced herself, her life and the external object as futile and disappointing after repeated failure to satisfy her grandiose fantasies about the search for ideal love. The patient then gave up her formerly gratifying activities, and fell into a prolonged state of negative emotions and passivity dominated by pessimistic mood characterized by an overwhelming sense of futility. The patient did not respond to medical treatment with antidepressants firstly. However after a 2-year course of intensive psychotherapy, the patient was able to restore her zest to find a new boyfriend with a more rational and realistic attitude. Clinically, decompensated narcissistic patients do not exhibit the typical attitude of worthlessness or guilty feelings, and are devoid of certain specific depressive emotions (e.g., sadness, sorrow, etc.). In contrast, decompensated narcissistic patients with pessimistic mood exhibit a dominant sense of futility and other negative emotions presented as outrage and disappointment. The purpose of this case report was to emphasize the importance to recognize clinical features of pessimistic mood for the differential diagnosis and management of the decompensated narcissistic patient.

Catatonic features noted in patients with post-partum mental illness

The purpose of the present study was to investigate the prevalence, distribution of psychiatric diagnoses, and treatment responses of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung in Taiwan. During a 1 year period a total of 636 Taiwanese women received psychiatric consultation on their visits to the emergency room. Fifteen of these were noted to have post-partum mental illnesses. All subjects were followed up for a minimum of 3-6 months. The prevalence of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung was 2.4% (15/636). The distribution of psychiatric diagnoses according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria included eight cases of major depressive disorders (53.3%), three cases of bipolar I disorder (20%), three cases of schizophrenia (20%), and one case of psychotic disorder due to a general medical condition (6.7%). Four subjects manifested catatonic features. Of these four, three had complete remission in catatonic symptoms after receiving intramuscular injection of lorazepam. The fourth subject died of multiple medical diseases. The treatment results suggest that most of the clinical presentations in patients with post-partum mental illness could be relieved by antipsychotics, mood stabilizers or antidepressants. In addition, it was found that intramuscular injection of lorazepam was also effective in patients with catatonic features and post-partum depression or psychosis.

Correlation between serum lipid, lipoprotein concentrations and anxious state, depressive state or major depressive disorder

The purpose of this study was to investigate the correlation between serum lipid, lipoprotein concentrations and anxious state, depressive state or major depressive disorder. A total of 207 patients admitted for general health screening were recruited during a 1-year period. Using the Chinese Health Questionnaire, the Taiwanese Depression Questionnaire and the semi-structured clinical interview for DSM-IV, one psychiatrist screened all participants for the presence of anxiety or depressive disorders. Blood samples for serum lipid and lipoprotein concentrations and physical examination records were collected simultaneously. For patients who did not have systemic diseases (n=162), we found that high-density lipoprotein (HDL) cholesterol and the ratio of total cholesterol (TC)/HDL differed significantly among anxious state, depressive state and normal groups in men after age adjustment. On the other hand, the ratios of TC/HDL and low-density lipoprotein (LDL)/HDL showed significant differences between patients with major depressive disorder and normal controls in women. This study suggested that the level of HDL cholesterol and the ratios of TC/HDL and LDL/HDL (atherogenic index) might be another markers of the possible association between serum lipids and anxiety or depression.

Decreased serum albumin levels in Taiwanese patients with schizophrenia

Previous papers have reported lower serum albumin levels in patients with schizophrenia. In the present study, the relationships between serum albumin levels and subtypes of schizophrenia, physical violence and suicide attempts were investigated. A review of medical charts over a 1-year period was carried out in a population of 213 Taiwanese psychiatric inpatients that included 106 patients with schizophrenia. The collected data included age, bodyweight, height, serum albumin levels and routine blood biochemistry examinations. These data were compared with data from a healthy control group (n = 32) composed of staff members using analysis of covariance after age adjustment. The statistical results showed significantly lower serum albumin levels in patients with schizophrenia in the acute phase than in the control group. However, no significant differences in serum albumin levels were found between paranoid and non-paranoid schizophrenic patients, between patients who had or had not exhibited physical violence, or between patients who had or had not made a suicide attempt.

Lower serum albumin levels in patients with mood disorders

BACKGROUND

Some physicians have reported lower serum albumin levels in patients with major depression in Western countries. In this study, the relationship between serum albumin levels and mood disorders (including mania and major depression) was investigated during the acute phases in Taiwanese psychiatric inpatients.

METHODS

A review of medical charts during a 1-year period was carried out in a population of 213 Taiwanese psychiatric inpatients that included 61 patients with mood disorders (with or without suicide attempts). The collected data included age, body weight, height, serum albumin levels, and routine blood biochemistry examination results. These data were compared with data from a healthy control group (N = 32) drawn from the staff of the psychiatric ward. Statistical analysis was done using covariance after age adjustment.

RESULTS

The mean serum albumin levels were 40.2 +/- 4.0 g/L in patients with mania (N = 25), 39.8 +/- 2.8 g/L in patients with major depression (N = 36), and 45.8 +/- 2.0 g/L in the control group. Patients with mania (F = 64.6, p = 0.000) and major depression (F = 68.9, p = 0.000), respectively, had significantly lower albumin levels than the control group after age adjustment. However, for the patients with major depression, no significant difference in serum albumin levels were found between patients who had attempted suicide and those who had not.

CONCLUSION

Lower serum albumin levels were noted during the acute phases of mania and major depression in Taiwanese psychiatric inpatients.

Single imaging modality evaluation of living donors in liver transplantation: magnetic resonance imaging

BACKGROUND

Liver graft size, anatomy of the bile duct and the vascular inflow and outflow are essential for living related liver transplantation (LRLT). Preoperative delineation of those variations that would change the operative procedure to achieve a successful result especially in an emergency condition.

PURPOSE

Our aim was to develop a rapid and noninvasive imaging diagnostic method for the detection of anatomical variants that is mandatory for a safe operation when selecting potential liver transplant living donors. We used a different magnetic resonance (MR) imaging technique, which enabled to us to exploit the anatomical landmark of the liver, signal enhancement of blood flow in the abdomen, and the intrahepatic biliary routes inside the liver. Then, with the help of Advantage Window workstation reconstruction, the reconstructed single vascular or biliary systems were displaced in a three-dimensional fashion and the whole examination finished within 30 min.

METHODS

Modification of the standard MR technique was performed on a superconductive 1.5T whole body image scanner, MR arteriogaphy, venography, and cholangiography with three-dimensional reconstruction in evaluating the anatomy of the hepatic arteries, hepatic veins, portal venous system, bile ducts, and liver size in potential liver transplant living donors. These anatomical structures were compared with traditional imaging methods.

RESULTS

In all 38 cases, as well as delineation of the portal vein detail to the segmental level was satisfactorily obtained in this MR study. The images were well displayed in a three-dimensional fashion, which had good correlation with images from traditional imaging modalities and operative findings. In 86.8% cases, the MR arteriography was well matched with the celiac angiography. Of those 17 operative cases, estimation of liver volume was well correlated with the liver graft within 3.9-12.5% variation. In the major hepatic vein, we obtained 100% accuracy and 88.2% in the minor branches. Of 12 donors received intraoperative cholangiography during liver donation, good correlation of biliary anatomy was achieved. One donor was excluded from graft donation due to the complicated arterial supply to the left liver. According to the anatomical variation, surgical procedures in graft harvesting and anastomosis were readjusted and no major complications were found in those donors and all recipients survived after liver transplantation.

CONCLUSION

MR volumetry, venography, angiography, and cholangiography with three-dimensional reconstruction is sufficient for all major imaging evaluation. It may replace the traditional conventional catheter angiography, computed tomography, sonography and endoscopic retrograde cholangiography as a single investigation in the evaluation of the potential liver transplant donors. Angiography is only valuable in suboptimal cases and intraoperative cholangiography is only performed in biliary ductile variants.

N,N'-bis[4-(N-alkylamidino)phenyl]homopiperazines as anti-Pneumocystis carinii agents

The synthesis, anti-Pneumocystis carinii activity and DNA binding properties of eight new N,N'-bis[4-(N-alkylamidino)phenyl]homopiperazines are reported. Compounds 2 and 8 were the most potent and caused about 70% inhibition of Pneumocystis carinii growth in a cell culture model at 1 microM concentrations.

Serum cholesterol levels in mood disorders associated with physical violence or suicide attempts in Taiwanese

BACKGROUND

Many previous studies have discussed the relationships between serum cholesterol levels and depression, violence and suicide in Western countries. In this paper, the relationships between serum cholesterol levels and mood disorders, physical violence and suicide attempts in Taiwanese psychiatric inpatients were reported.

METHODS

A review of medical charts over a 1-year period was carried out in a population of 213 Taiwanese psychiatric inpatients that included 61 patients with affective disorders. The collected data included age, body weight, height, and serum cholesterol levels.

RESULTS

There were no significant differences in the serum cholesterol levels between patients with mania and major depression, between patients with and without physical violence, or between patients who had and had not made a suicide attempt using analysis of covariance after age or body mass index adjustment.

CONCLUSION

Due to the limitations of case numbers and study methods, the results need to be further clarified with larger numbers of patients and in controlled studies.

Neuroleptic malignant syndrome associated with long-term clozapine treatment: report of a case and results of a clozapine rechallenge

Clozapine has recently been found to be associated with neuroleptic malignant syndrome (NMS) after long-term treatment. Here, I report on a 34-year-old Taiwanese woman who had been diagnosed with schizophrenic disorder 17 years previously. She had received clozapine 250 mg/day monotherapy for 7 years. She had sudden onset of NMS signs with high fever, profuse diaphoresis, severe muscular rigidity, elevated creatine phosphokinase level and consciousness disturbance. Brain computed tomography, blood culture and cerebral spinal fluid studies were negative. She had no muscle rigidity and fever after treatment with normal saline 1500 ml/day and diazepam 30 mg/day for 8 days. On day 15, a rechallenge with clozapine was done with caution because the patient was experiencing auditory hallucinations and delusions of persecution. The dose was slowly increased to 250 mg/day over 18 days. She had no active psychotic symptoms or NMS again in the following year. I reported this case to remind readers of the possibility of induced NMS with long-term use of clozapine and successful clozapine rechallenge.