[Hemophagocytic syndrome]

INTRODUCTION

Hemophagocytic syndrome results from a inappropriate stimulation of macrophages in bone marrow and lymphoid organs, leading to phagocytosis of blood cells and production of high amounts of pro-inflammatory cytokines. This life-threatening disease combines non-specific clinical signs (fever, cachexia, hepatomegaly, enlargement of spleen and lymph nodes) as well as typical laboratory findings (bi- or pancytopenia, abnormal hepatic tests, hypofibrinemia, elevation of serum LDH, ferritinemia and triglyceride levels). Diagnosis is confirmed by cytological or pathological examination of bone marrow or tissue specimens. Hemophagocytosis may be primitive, essentially in pediatric population, or secondary, related to various situations such as lymphomas, infections (viral, bacterial or parasitic) or auto-immune diseases. Prognosis is poor, depending on the associated disease, with an overall mortality of 50%.

CURRENT KNOWLEDGE AND KEY POINTS

Recent advances, essentially due to genetic studies of familial hemophagocytic syndrome, have underlined the major role of T lymphocytes and TNF alpha in the pathogenesis of hemophagocytosis. In these pediatric cases, prognosis has dramatically improved since allogenic bone marrow transplantation is performed, raising long-term survival from 10 to 66%.

FUTURE PROSPECTS AND PROJECTS

In secondary forms of hemophagocytic syndrome, treatment must be symptomatic (transfusion, correction of electrolyte disorders) and etiological (chemotherapy, anti-viral or antibiotic drugs, immunosuppressive therapy). However, prospective trials are necessary to define the best treatment in these cases. New therapeutic options, targeting specific mediators, including TNF alpha, may emerge with the understanding of pathogenesis of hemophagocytic syndrome.

[Treatment of severe botulism with 3,4-diaminopyridine]]

INTRODUCTION

The specific treatments of botulism with serotherapy and with guanidine are of debatable efficacy. We report a case of nutritional toxin B botulism successfully treated with 3,4-diaminopyridine.

OBSERVATION

Following a meal, a 69 year-old woman consulted for digestive disorders followed by damage to several cranial pairs, autonomous nervous system and ventilation command, motivating mechanical ventilation on tracheal intubation. Administration of symptomatic treatment with 3,4-diaminopyridine led to progressive improvement, although the diagnosis of toxin B botulism was confirmed.

COMMENTS

Administration of 3,4-diaminopyridine, the efficacy of which had been suggested by the review of experimental literature, led to rapid and clear improvement, probably due to its potentiating effect on acetylcholine release in the neuromuscular junction.

A comparison of inpatients in an urban state hospital in 1975 and 1982

To investigate whether there had been a rise in admissions of young, chronic, antisocial patients at a state psychiatric hospital in New York City, the authors compared 50 patients admitted in 1975 and 49 admitted in 1982 on demographic characteristics, inpatient history, and history of antisocial behavior in the community and during the hospitalization. The cohorts had comparable demographic characteristics, lengths of stay, and overall histories of antisocial behavior. However, the percentages of patients who committed assault and had encounters with the criminal justice system while living in the community were significantly higher in the 1982 cohort, as was the proportion of men who engaged in antisocial behavior in the community. The incidence of episodes of violence and of seclusion and restraint during hospitalization was significantly higher among the 1982 cohort but was not related to antisocial behavior in the community or age. The authors conclude that urban state psychiatric hospitals may have experienced a rise in admissions of antisocial patients but that current data do not explain why.

Strategies for reducing missed initial appointments in a community mental health center

The present study attempted to reduce the missed initial appointment rate of an urban CMHC through the use of several intervention strategies. Individuals who called for an intake appointment were randomly assigned to either a control group or one of the following treatment conditions: orientation statement at the time the appointment was made, orientation statement plus phone prompt, or phone prompt only. The orientation statement only group had significantly fewer missed initial appointments than the control group (28% vs. 56%). A client reachability factor also played a role in predicting missed initial appointments.

Methadone evaluation: some additional thoughts

This study of 460 patients showed that the 37% of the patients who were terminated as program failures did significantly worse than the active patients in terms of drug abuse, criminality, and social productivity. These findings suggest that methadone maintenance is at best a marginally effective modality for those large numbers of patients who drop out. Assuming that it is preferable for these dropouts to be on a program rather than on the streets, methadone maintenance treatment programs probably need to be more flexible so as to retain a larger number of these dropouts.

The usefulness and reliability of a drug severity scale

This paper reports on the interrater reliability of a previously developed method for measuring severity of multidrug use. This method is based on interviewer's ratings of the number of different drugs used, the frequency of use, and the length of use of each drug. The results show that relatively unsophisticated raters in comparison with trained and experienced raters are able to utilize the drug severity form with a minimum of error.

Taste thresholds in twins and siblings

Monozygotic twin (MZ), dizygotic twin (DZ), and sibling (SIB) pairs were taste-tested for hydrochloric acid, 1-quinine sulfate, and 6-n-propylthiouracil (PROP). The numbers of pairs involved were 75 MZ, 70 DZ, and 78 SIB, for the latter two compounds; 26, 45, and 45, respectively, for the acid.

There was a significant difference in intrapair variance, between the MZ and the same-sex DZ pairs, in thresholds for bitter-tasting 6-n-propylthiouracil (p < .001). The difference in intrapair threshold variance was not significant for bitter-tasting quinine (p > .05) or for sour-tasting hydrochloric acid (p > .10).

The male MZ pairs had a significantly lower intrapair threshold variance than the male DZ or male SIB pairs for hydrochloric acid (p < .01), but the female pairs manifested no such difference. The intrapair variance in hydrochloric acid threshold was significantly less for the nine male MZ pairs than for the 17 female MZ pairs (p < .02).

Repeated taste tests on the same subjects reproduced results similar within a single threshold range in a high proportion for each compound: for hydrochloric acid, 72.9% (N = 44); for quinine, 76.9% (N = 221); and for PROP, 76% (N = 225).

Correlations between thresholds for the different substances were positive and significant (N = 308): between PROP and quinine, r = + 0.44 ± .05 (p < .01); between quinine and hydrochloric acid, r = + 0.35 ± .05 (p < .01); between PROP and hydrochloric acid, r = + 0.17 ± .06 (p < .05).