Valproic acid use in psychiatry: issues in treating women of reproductive age

Valproic acid, a well known anticonvulsant, is being used by psychiatrists increasingly to manage bipolar and other affective disorders. Because of the demographics of the population affected by such psychiatric conditions, more women of childbearing age are likely to be exposed to this teratogenic drug. Neural tube defects (NTD) are the most common of the major anomalies associated with in utero valproic acid exposure, and are estimated to occur in 1% to 2% of exposed fetuses. Other teratogenic effects include facial dysmorphism, congenital cardiac defects, limb reduction defects and other skeletal anomalies. Prenatal diagnosis, in particular maternal serum alpha-fetoprotein screening and targeted ultrasonography, should be offered to all pregnant women exposed to valproic acid and couples need to be aware of the prenatal diagnostic options available to them. Periconceptual prophylaxis with high doses of folic acid is recommended for all women on valproic acid and counselling should also emphasize planning pregnancy to optimize folic acid supplementation. Psychiatrists should be aware of the teratogenic potential of valproic acid and know how to counsel their patients of reproductive age.

Visual loss in a returning traveller with tick typhus

Rickettsial diseases are increasingly found world-wide and should be considered in febrile patients returning from abroad. This case report describes the vasculitic complications of a patient returning from the Republic of South Africa with tick typhus.

Effective in vivo depletion of T cell subpopulations and loss of memory cells in cattle using mouse monoclonal antibodies

Conditions were established to obtain depletion of T lymphocyte subsets in lymphoid tissues of calves by injection of mouse monoclonal antibodies to T cell antigens. Adverse reactions were avoided by injecting small quantities of antibody, until target cells had disappeared from blood. Two different mechanisms appeared to be responsible for elimination of the target cells. Rapid depletion of T cells was associated with complement-binding antibody isotypes (IgG2a, IgM), suggesting a complement-mediated mechanism. Clearance of T cells after several days was observed with a non complement-binding isotype (IgG1), suggesting phagocytosis or induction of apoptosis as possible mechanisms. Clearance of the cells in peripheral blood and spleen was obtained with 10-20 mg of anti-CD4 or anti-CD8, but almost ten times as much was needed to obtain depletion of the cells in lymph nodes and Peyer's patches. Depletion lasted for 12 days for CD4 T cells and 3 weeks for CD8 T cells. Successful and lasting depletion (at least 2 weeks) was also obtained with other T cell reagents, such as anti-CD2 and anti-WC1 (gamma/delta T cells). Although B lymphocytes could be removed by a complement-binding antibody, complete depletion of these cells only lasted for a few hours, probably because B cells regenerate faster than T cells. T cell function was severely inhibited when CD4+ T cells were depleted. Stimulation of T cells with foot and mouth disease viral antigen (FMDV) in vaccinated calves was non-existent after depletion. Even 2 months after restoration of normal CD4 T cell levels in blood, activity to FMDV was low. This suggested that the depleted T cells were replaced by naive cells.

Cocaine decreases cortical cerebral blood flow but does not obscure regional activation in functional magnetic resonance imaging in human subjects

The authors used functional magnetic resonance imaging (fMRI) to determine whether acute intravenous (i.v.) cocaine use would change global cerebral blood flow (CBF) or visual stimulation-induced functional activation. They used flow-sensitive alternating inversion recovery (FAIR) scan sequences to measure CBF and blood oxygen level-dependent (BOLD) sensitive T2* scan sequences during visual stimulation to measure neuronal activation before and after cocaine and saline infusions. Cocaine (0.6 mg/kg i.v. over 30 seconds) increased heart rate and mean blood pressure and decreased end tidal carbon dioxide (CO2). All measures returned to baseline by 2 hours, the interinfusion interval, and were unchanged by saline. Flow-sensitive alternating inversion recovery imaging demonstrated that cortical gray matter CBF was unchanged after saline infusion (-2.4 +/- 6.5%) but decreased (-14.1 +/- 8.5%) after cocaine infusion (n = 8, P < 0.01). No decreases were detected in white matter, nor were changes found comparing BOLD signal intensity in cortical gray matter immediately before cocaine infusion with that measured 10 minutes after infusion. Visual stimulation resulted in comparable BOLD signal increases in visual cortex in all conditions (before and after cocaine and saline infusion). Despite a small (14%) but significant decrease in global cortical gray matter CBF after acute cocaine infusion, specific regional increases in BOLD imaging, mediated by neurons, can be measured reliably.

Prenatally diagnosed neural tube defects: ultrasound, chromosome, and autopsy or postnatal findings in 212 cases

From January 1990 until December 1996, 212 cases of neural tube defect (NTD) were seen through the Prenatal Diagnosis Program of the University of Toronto. Of the 212 cases, 200 were karyotyped successfully and of these, 13 (6.5%) had chromosome abnormalities. When classified according to the site of the NTD, 2.3% (2/88) of anencephalics, 7.1% (1/14) of encephaloceles, and 10.2% (10/98) of meningomyeloceles had abnormal karyotypes. The absence of associated ultrasound abnormalities was not necessarily predictive of a chromosomally normal fetus; 4/167 (2.4%) of fetuses with isolated NTDs had chromosome abnormalities. Conversely, 24/33 (72%) of fetuses with additional findings on ultrasound had normal chromosomes. The diagnosis of a chromosome abnormality associated with NTD has important implications for recurrence risk and prenatal diagnosis, not only for the parents but potentially for other relatives. Based on our finding that 6.5% of prenatally detected NTDs are associated with chromosome abnormalities, we recommend karyotyping of all fetuses and/or newborns with NTD.

The use of alternative therapies by children with asthma: a brief report

OBJECTIVE

To identify the nature and prevalence of alternative therapies used by children with asthma attending a children's hospital.

METHODOLOGY

Subjects consisted of a consecutive series of 51 children with asthma aged 1-6 years who were attending the Women's and Children's Hospital, South Australia. Parents of the children completed a questionnaire describing the use of alternative therapies by the children.

RESULTS

Approximately 55% of children used alternative therapies for asthma management. Therapies used most commonly were massage, relaxation exercises, diet therapy and vitamins. There was no significant difference in the age, asthma severity, length of time since diagnosis or presence of another illness amongst children who did or did not use alternative therapies.

CONCLUSIONS

A substantial proportion of children with asthma who attend paediatric clinics use alternative therapies. Paediatricians should be aware of this and be prepared to discuss alternative therapies with parents. This may facilitate more open doctor-patient relationships and better management of children's asthma.

Identification of an immunodominant IgE epitope of the Parietaria judaica major allergen

Par j 1.0101 is one of the two major allergens of the Parietaria judaica (Pj) pollen, and its three-dimensional structure was built by three-dimensional structural homology modeling. The resultant model was used to identify putative IgE binding regions. Western blot analysis of gene fragmentation products showed that the 1 to 30 region was capable of binding specific IgE from a pool of sera (n = 30) of patients allergic to Pj pollen. Using the structural model as a guide, deletion and site-directed mutagenesis of the 1 to 30 region was performed, and the amino acids involved in IgE binding were identified. In addition, a synthetic peptide covering the 1 to 30 region was capable of binding human IgE without triggering histamine release from basophils of Pj allergic patients (n = 6) and thus represents a haptenic molecule with potential use as an immunotolerant agent. This epitope is also present on the Par j 2.0101 major allergen representing a common IgE epitope. It is an immunodominant epitope, since it was capable of inhibiting 30% of all specific IgE against the Pj major allergens, and therefore, it might be a candidate for the future development of immunotherapeutics.

The selective impairment of the perception of first-order motion by unilateral cortical brain damage

First-order (Fourier) motion consists of stable spatiotemporal luminance variations. Second-order (non-Fourier) motion consists instead of spatiotemporal modulation of contrast, flicker, or spatial frequency. In spite of extensive psychophysical and computational analysis of the nature and relationship of these two types of motion, it remains unclear whether they are detected by the same mechanism or whether separate mechanisms are involved. Here we report the selective impairment of first-order motion, on a range of local and global motion tasks, in the contralateral visual hemifield of a patient with unilateral brain damage centered on putative visual areas V2 and V3 in the medial part of the occipital lobe. His perception of second-order motion was unimpaired. As his disorder is the obverse of that reported after damage in the vicinity of human visual area MT (V5), the results support models of motion processing in which first- and second-order motion are, at least in part, computed separately at the extrastriate cortical level.

Moderate alcohol consumption during pregnancy and the incidence of fetal malformations: a meta-analysis

To determine whether there is an association between moderate alcohol consumption in the first trimester of pregnancy and increased risk of fetal malformations, we conducted a literature search using Medline (1966-present), PsycLit (1974-1995), and EMBASE (1988-1995). The following inclusion criteria were used to select the studies to be evaluated: 1) pregnant women; 2) moderate alcohol consumption (> 2 drinks/week to 2 drinks/day); 3) case-control or cohort studies; 4) presence of an abstainer group (0 to 2 drinks/wk); 5) outcome measures include major or minor malformations; 6) papers published in the English language. The exclusion criteria were: 1) studies in which moderate alcohol consumption could not be confirmed; 2) case reports, and editorials. The Methods section of each study was examined independently by two blinded investigators with a third investigator settling any disagreement. The number of malformations in the abstainer and moderate alcohol consuming groups in two by two tables. Out of 24 studies which met the inclusion criteria, only seven had extractable data. The included studies evaluated 130,810 pregnancy outcomes, with 24,007 in the moderate alcohol group and 106,803 in the control group. An overall Mantel-Haenszel odds ratio showed that the relative risk for fetal malformations was 1.01 with 95% confidence limits of 0.94 to 1.08 and a chi-square for homogeneity of 8.26 (p = 0.220). Quality of the studies did not correlate with their showing negative or positive association. Moderate alcohol consumption during the first trimester of pregnancy is not associated with increased risk of fetal malformations.

Reduced subcortical brain volumes in nonpsychotic siblings of schizophrenic patients: a pilot magnetic resonance imaging study

Substantial evidence suggests that nonpsychotic relatives of schizophrenia patients manifest subtle abnormalities in communication, eye movements, event-related potentials, and neuropsychological processes of attention, reasoning, and memory. We sought to determine whether adult relatives without psychosis or schizophrenia spectrum diagnoses might also have structural brain abnormalities, particularly in subcortical regions found to be impaired in patients with schizophrenia itself. Subjects were six sisters of schizophrenic patients and eleven normal female controls. Sixty contiguous 3 mm coronal, T1-weighted 3D magnetic resonance images (MRI) of the entire brain were acquired on a 1.5 Tesla magnet. Cortical and subcortical gray and white matter was segmented using a semiautomated intensity contour mapping algorithm. Volumes were adjusted for total brain volumes. Adjusted gray matter subcortical volumes were significantly smaller in relatives than in controls in total hippocampus, right amygdala, right putamen, left thalamus, and brainstem. Relatives had significantly enlarged left and total inferior lateral ventricles. These results, though preliminary, suggest that some never-psychotic relatives of schizophrenic patients have abnormal brain structure. If replicated in a larger sample including both sexes, these results would suggest that the genetic liability to schizophrenia is also expressed as structural brain abnormalities.

Managing burnout in pediatric critical care: the human care commitment

Burnout in social services professionals has been defined as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. The pediatric critical care nurse is especially vulnerable to this phenomenon when exposed to prolonged, chronic suffering of a patient. The rewarding aspect of caring for the critically ill child who recovers from significant affliction is not experienced when caring for the "chronic child." This article reviews the dynamics of chronicity in pediatric critical care and explores protective strategies for burnout management. Several of Jean Watson's carative factors that define her human care philosophy provide the conceptual framework for the approaches outlined.

Sinusitis: bench to bedside. Current findings, future directions

Sinusitis, an inflammatory disease of the sinus, is one of the most commonly reported diseases in the United States, affecting an estimated 14% of the population. The prevalence of sinusitis is rising. Between 1990 and 1992, persons with sinusitis reported approximately 73 million restricted activity days-an increase from the 50 million restricted activity days reported between 1986 and 1988. Because critical questions remain unanswered about its cause, pathophysiology, and optimal treatment, sinusitis continues to generate significant health care costs and affects the quality of life of a large segment of the U.S. population. To identify critical directions for research on sinus disease, the American Academy of Allergy, Asthma and Immunology and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc., convened a meeting in January 1996 in collaboration with the National Institutes of Allergy and Infectious Disease. This document summarizes the proceedings of that meeting and presents what is intended to be the background for future investigation of the many unanswered questions related to sinusitis.

Sinusitis: bench to bedside. Current findings, future directions

Sinusitis, an inflammatory disease of the sinus, is one of the most commonly reported diseases in the United States, affecting an estimated 14% of the population. The prevalence of sinusitis is rising. Between 1990 and 1992, persons with sinusitis reported approximately 73 million restricted activity days--an increase from the 50 million restricted activity days reported between 1986 and 1988. Because critical questions remain unanswered about its cause, pathophysiology, and optimal treatment, sinusitis continues to generate significant health care costs and affects the quality of life of a large segment of the U.S. population. To identify critical directions for research on sinus disease, the American Academy of Allergy, Asthma and Immunology and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc., convened a meeting in January 1996 in collaboration with the National Institutes of Allergy and Infectious Disease. This document summarizes the proceedings of that meeting and presents what is intended to be the background for future investigation of the many unanswered questions related to sinusitis.

A case-control study to identify farm factors affecting fertility of dairy herds: univariate description of factors

OBJECTIVE

To identify farm factors which were associated with reproductive performance in dairy herds in New South Wales.

PROCEDURE

A survey was administered by face to face interview to examine the responses of producers drawn from 757 herds, which used the New South Wales Agriculture Department Dairy Herd Improvement scheme. A case-control approach was used to select a total of 126 herds from the first (top group-cases) and fourth quartiles (low group-controls) for intercalving interval.

RESULTS

We found that the estimated interval from calving to first mating was significantly different between group (P = 0.03) and that the groups significantly differed in both their target for interval to first mating (P = 0.02) and their perceived optimum time for first mating (P = 0.04). Other factors associated with a longer intercalving interval included, use of embryo transfer programs (P = 0.08), younger managers (P = 0.02), fewer breedings per day (P = 0.01), a greater number of people detecting heats (P = 0.07), but less hours spent detecting heats while handling the cows (P = 0.11), and a failure to vaccinate bulls for campylobacteriosis (P = 0.14).

CONCLUSIONS

Managers of herds with poorer reproductive performance did not intend to mate cattle as soon after calving as managers with better reproductive performance, were not as active in seeking veterinary advice on reproduction, and were attempting to treat reproductive diseases and disorders themselves.

Pathogenesis and evolution of plexiform lesions in pulmonary hypertension associated with scleroderma and human immunodeficiency virus infection

Patients with primary pulmonary hypertension develop vascular lesions characterized by proliferated blood channels, the so-called plexiform lesions. These lesions are often associated with concentric intimal obliteration of pulmonary vessels. We report that the lungs of three patients with scleroderma-associated pulmonary hypertension showed a predominance of obliterative-concentric lesions, with relatively few plexiform or combined lesions. In contrast, plexiform lesions predominated in the lungs obtained from three patients with human immunodeficiency virus (HIV)-associated pulmonary hypertension; pure obliterative-concentric lesions were infrequent. Both plexiform and concentric obliterative lesions stained strongly positive for the endothelial cell marker factor VIII-related antigen. Muscle-specific actin immunostaining highlighted the smooth muscle cells of the tunica media of plexiform vessels, but not the luminal layers of the concentric-obliterative lesions. Proliferating cells, as determined by immunostaining with the MIB-1 antibody, were only detected in the plexiform vascular lesions. We postulate that concentric-obliterative lesions and plexiform lesions are temporally and etiologically related. A scaffolding of proliferating endothelial cells could be the common denominator of both lesions. Our hypothesis that there exists a chronological continuum, proceeding from early, proliferative plexiform lesions to late, nonproliferative concentric-obliterative lesions in primary and secondary pulmonary hypertension, may lead to better targeted treatment strategies and disease classification.

Trypanosoma congolense: a comparison of T-cell-mediated responses in lymph nodes of trypanotolerant and trypanosusceptible cattle during primary infection

A comparison of T-cell-mediated immune responses in trypanotolerant N'Dama and susceptible Boran cattle during primary infection with tsetse-transmitted Trypanosoma congolense was conducted to assess whether different patterns of T-cell activation occurred during trypanosome infection. Proliferation and IFN-gamma synthesis in response to trypanosome antigens and to the mitogen Con A were measured in LNC before infection and 10 and 35 days postinfection. Phenotypic analysis of LNC was also carried out. No significant differences in the in vitro proliferation of LNC to VSG, to hsp70/BiP, or to Con A were detected between the breeds. In contrast, IFN-gamma production in response to Con A was higher in Boran cattle at 35 days p.i. A reduction in the number of CD2+ and CD4+ T-cells and an increase in the percentage of B-cells, CD8+ T-cells, and gamma delta T-cells during infection in both N'Dama and Boran was revealed by cytofluorimetric analysis of lymph node cells.

Medication "safety checks" in pediatric acute care

The high acuity of hospitalized pediatric patients requires well-articulated safety measures in medication dosing and administration. Simple arithmetic errors in calculating medication and fluid requirements can occur easily. A decimal point error could mean injury to a child because of the fine line between therapeutic and toxic effects of medications. This article identifies a few pediatric medication errors encountered by the author. Approaches by nursing professionals to decrease these occasions for mistakes are suggested in the context of creating a system that accepts and recognizes human error without placing blame.

Trypanosoma congolense: B-lymphocyte responses differ between trypanotolerant and trypanosusceptible cattle

Trypanosomiasis is a serious constraint to livestock production in sub-Saharan Africa. Some breeds of cattle are genetically more resistant to the pathogenic effects of trypanosome infection. We measured B-cell activation and the quantity and isotype of antibody produced at the cellular level in six trypanotolerant N'Dama and five trypanosusceptible Boran cattle. The frequencies of spleen cells secreting total and parasite-specific IgM and IgG were measured prior to and 16, 28, and 35 days after a primary challenge with Trypanosoma congolense. Boran cattle had higher frequencies of splenic cells secreting IgM specific for trypanosome-derived variable surface glycoprotein (VSG), cysteine protease (congopain, CP), and heat shock protein (hsp 70/BiP) and the nonparasite antigen, ovalbumin, than did N'Dama cattle. In contrast, the number of VSG-specific IgG-secreting cells was significantly greater in N'Dama than in Boran cattle. During infection, low titers of anti-VSG IgM were detected transiently in the serum of all animals. However, N'Dama had significantly more VSG-specific IgG in blood than Boran during infection. The peripheral blood mononuclear cell population of N'Dama cattle contained a higher percentage of surface IgM-positive B-cells prior to and throughout infection than were found in the blood of Boran. In addition, during infection N'Dama cattle had more circulating lymphocytes that could be activated in vitro to undergo differentiation into IgM- and IgG-secreting cells. These findings demonstrate differences in the frequency of trypanosome-specific antibody-secreting cells in the spleen and in the activation state of B-cells in the blood between N'Dama and Boran cattle during a primary infection with T. congolense.