0976 Temporal Associations Between Sleep And Suicidality In Ultra-high Risk Adolescents And College Students During An Intensive Longitudinal Study

Introduction

Studies consistently demonstrate a link between subjective sleep disturbances and the continuum of suicidality, although this evidence primarily comes from retrospective, cross-sectional studies using limited items to assess sleep. Longitudinal assessment of well-defined and measured sleep/wake behaviors with high-risk individuals are needed to enhance the specificity of near-term suicide risk detection and render concrete targets for suicide prevention.

Methods

Participants (N=46) included ultra-high-risk adolescents (N=29 ages 12-18) and college students (N=17 ages 18-24). For up to 12 weeks, participants wore an actigraph to yield objective data on sleep/wake, and concurrently completed daily cellphone-based ratings of subjective sleep and suicidality. Generalized estimating equations were used to examine the association between sleep parameters (subjective and objective) and the odds of next-day suicidal outcomes (i.e., passive death wish [PDW], suicidal ideation, suicidal intent) controlling for age, gender, and depression severity.

Results

Significant quadratic relationships were observed between actigraphy-derived total sleep time (TST) and probability of next-day PDW (Z=3.7, p=0.0002), suicidal ideation (Z=2.1, p=0.04), and suicidal intent (Z=2.78, p=0.006), with increasing suicidality at low and high values of TST. Low sleep efficiency (<75%) was associated with increased odds of next-day PDW (OR=1.24, Z=2.07, p=0.038). Subjectively (sleep diary measures), low sleep quality (<50 on 100-point scale) was associated with increased odds of next-day suicidal ideation (OR=1.57, Z=3.42, p<0.001), and longer sleep onset latency (>20 minutes) with next-day suicidal intent (OR=3.00, Z=2.37, p=0.018).

Conclusion

Poor sleep health may signal increasing suicide risk, and are modifiable risk factors. We document a significant temporal association whereby objectively-derived short and long TST and low sleep efficiency, as well as subjective sleep quality and sleep onset latency, predicts next day’s suicidality. Further understanding of the temporal association between sleep and suicidality may hold promise to inform real-time monitoring and preventive strategies. Interventions targeting these factors may therefore help reduce suicidality in high-risk youth.

Support

American Foundation for Suicide Prevention; University of Pittsburgh Clinical and Translational Science Institute

Bi-allelic Loss-of-Function CACNA1B Mutations in Progressive Epilepsy-Dyskinesia

The occurrence of non-epileptic hyperkinetic movements in the context of developmental epileptic encephalopathies is an increasingly recognized phenomenon. Identification of causative mutations provides an important insight into common pathogenic mechanisms that cause both seizures and abnormal motor control. We report bi-allelic loss-of-function CACNA1B variants in six children from three unrelated families whose affected members present with a complex and progressive neurological syndrome. All affected individuals presented with epileptic encephalopathy, severe neurodevelopmental delay (often with regression), and a hyperkinetic movement disorder. Additional neurological features included postnatal microcephaly and hypotonia. Five children died in childhood or adolescence (mean age of death: 9 years), mainly as a result of secondary respiratory complications. CACNA1B encodes the pore-forming subunit of the pre-synaptic neuronal voltage-gated calcium channel Ca_v2.2/N-type, crucial for SNARE-mediated neurotransmission, particularly in the early postnatal period. Bi-allelic loss-of-function variants in CACNA1B are predicted to cause disruption of Ca²⁺ influx, leading to impaired synaptic neurotransmission. The resultant effect on neuronal function is likely to be important in the development of involuntary movements and epilepsy. Overall, our findings provide further evidence for the key role of Ca_v2.2 in normal human neurodevelopment.

Comprehensive Cancer-Predisposition Gene Testing in an Adult Multiple Primary Tumor Series Shows a Broad Range of Deleterious Variants and Atypical Tumor Phenotypes

Multiple primary tumors (MPTs) affect a substantial proportion of cancer survivors and can result from various causes, including inherited predisposition. Currently, germline genetic testing of MPT-affected individuals for variants in cancer-predisposition genes (CPGs) is mostly targeted by tumor type. We ascertained pre-assessed MPT individuals (with at least two primary tumors by age 60 years or at least three by 70 years) from genetics centers and performed whole-genome sequencing (WGS) on 460 individuals from 440 families. Despite previous negative genetic assessment and molecular investigations, pathogenic variants in moderate- and high-risk CPGs were detected in 67/440 (15.2%) probands. WGS detected variants that would not be (or were not) detected by targeted resequencing strategies, including low-frequency structural variants (6/440 [1.4%] probands). In most individuals with a germline variant assessed as pathogenic or likely pathogenic (P/LP), at least one of their tumor types was characteristic of variants in the relevant CPG. However, in 29 probands (42.2% of those with a P/LP variant), the tumor phenotype appeared discordant. The frequency of individuals with truncating or splice-site CPG variants and at least one discordant tumor type was significantly higher than in a control population (χ2 = 43.642; p ≤ 0.0001). 2/67 (3%) probands with P/LP variants had evidence of multiple inherited neoplasia allele syndrome (MINAS) with deleterious variants in two CPGs. Together with variant detection rates from a previous series of similarly ascertained MPT-affected individuals, the present results suggest that first-line comprehensive CPG analysis in an MPT cohort referred to clinical genetics services would detect a deleterious variant in about a third of individuals.

Prevalence of the metabolic syndrome in patients presenting to the university hospital of the West Indies: a need to adopt proactive screening and specific management policy

Studies have shown that the metabolic syndrome (MetS), a major risk factor for the development of Type 2 diabetes mellitus and cardiovascular disease, is higher among psychiatric patients on antipsychotic medications than the general population. While studies on the prevalence of MetS in the Jamaican adult population have been undertaken, no such study has been done on the corresponding psychiatric population. The purpose of this study was to determine the prevalence of MetS in a Jamaican adult psychiatric inpatient population. The study group comprised thirty-eight patients with a primary DSM-IV-TR Axis 1 diagnosis. Criteria for the diagnosis of MetS were the presence of any three or more of five factors as defined by using the International Diabetes Federation (IDF) and American Heart Association/National Heart Lung and Blood Institute (AHA/NHLBI) consensus agreement. The prevalence of MetS in this cohort was 28.9% and was associated with significantly higher abdominal obesity (p = 0.010), elevated blood pressure (p = 0.000), elevated triglycerides (p = 0.019) and low high density lipoprotein-cholesterol (p = 0.016) when compared with patients not diagnosed with MetS. Metabolic syndrome was common in this group of psychiatric patients and likely represents a pathway to the future development of Type 2 diabetes mellitus and cardiovascular disease. Screening and continuous monitoring will allow for early intervention and possibly prevention of increased morbidity and mortality in this vulnerable population.

Guideline on the investigation and management of acute transfusion reactions. Prepared by the BCSH Blood Transfusion Task Force

Although acute non-haemolytic febrile or allergic reactions (ATRs) are a common complication of transfusion and often result in little or no morbidity, prompt recognition and management are essential. The serious hazards of transfusion haemovigilance organisation (SHOT) receives 30-40 reports of anaphylactic reactions each year. Other serious complications of transfusion, such as acute haemolysis, bacterial contamination, transfusion-related acute lung injury (TRALI) or transfusion-associated circulatory overload (TACO) may present with similar clinical features to ATR. This guideline describes the approach to a patient developing adverse symptoms and signs related to transfusion, including initial recognition, establishing a likely cause, treatment, investigations, planning future transfusion and reporting within the hospital and to haemovigilance organisations. Key recommendations are that adrenaline should be used as first line treatment of anaphylaxis, and that transfusions should only be carried out where patients can be directly observed and where staff are trained in manging complications of transfusion, particularly anaphylaxis. Management of ATRs is not dependent on classification but should be guided by symptoms and signs. Patients who have experienced an anaphylactic reaction should be discussed with an allergist or immunologist, in keeping with UK resuscitation council guidelines.

Decriminalization of marijuana: is this a realistic public mental health policy for Jamaica?

Marijuana has potential benefits and adverse effects. Despite its popularity in Jamaica, decriminalization may not be possible given the international and regional obligations of Jamaica.

Pitfalls in the diagnosis of latex allergy

BACKGROUND

Screening patients for latex allergy prior to surgery is an important but intensive procedure. The appropriate testing strategy for diagnosing latex (Hevea brasiliensis) allergy involves in-vitro specific IgE or skin prick testing. The sensitivity and specificity of both tests are influenced by patient-specific factors or manufacturing processes that alter the clinically relevant allergens in skin testing solutions.

METHODS

Total IgE and latex-specific IgE testing was introduced as a screening test. Skin prick testing was done on patients with a high probability of latex allergy and negative specific IgE with total IgE <100 kU/L. SDS-PAGE was done on the non-ammoniated latex (NAL) and newly introduced ammoniated latex (AL) reagents for the clinically relevant allergens.

RESULTS

51 patients had a total IgE <100 (range, 2.8-99.0 kU/L), and 10% had a positive skin test. 60% of positive skin tests would have been missed with lower total IgE cut-offs of 50 kU/L (6% of referrals). SDS-PAGE of the NAL solution showed 3 prominent bands with molecular weights of approximately 20, 24 and 42 kDa that correlated with Hev b 6, Hev b 3 and Hev b 7/13, respectively. In contrast, the AL solution showed 3 very faint higher molecular weights bands that did not correlate with clinically relevant antigens.

CONCLUSIONS

Increasing the cut-off value of total IgE for allergen-specific IgE testing increased the sensitivity of the specific IgE test. The NAL reagent had a greater number of clinically significant allergens at higher concentrations than AL, which may have implications for the clinical sensitivity of the newer AL reagent.

Adjunctive high-dose intravenous immunoglobulin treatment for resistant atopic dermatitis: efficacy and effects on intracellular cytokine levels and CD4 counts

Although atopic dermatitis generally responds to topical therapy, small numbers of patients have severe resistant disease despite second-line therapies. High-dose intravenous immunoglobulin has been suggested to be of benefit in a small number of reports. We have conducted an open, single-centre study of adjunctive high-dose intravenous immunoglobulin (Flebogamma 5%). Six patients received treatment at 2 g kg(-1) month(-1) for 6 cycles, with a 3-month follow-up period. Skin scores, lymphocyte phenotypes and intracellular cytokine analysis were performed. Four of six patients had major improvements in skin scores and the overall reduction was significant (p = 0.035). CD4+ T-cell numbers fell following high-dose intravenous immunoglobulin infusions, recovering by the next cycle. T-cell CD69 expression decreased to 60% of baseline values. Reductions in the proinflammatory cytokines IFN-gamma and TNF-alpha were non-significant. Adjunctive high-dose intravenous immunoglobulin may be a useful therapeutic approach in adults with severe treatment-resistant atopic dermatitis, but it will require further assessment in randomized controlled trials to establish this.

Estimation of cumulative exposure to organophosphate sheep dips in a study of chronic neurological health effects among United Kingdom sheep dippers

OBJECTIVES

To derive a method for retrospectively estimating cumulative exposure to organophosphate (OP) pesticides among a cross section of United Kingdom sheep dippers, as part of a wider epidemiological study of neurological abnormality within this group of workers.

METHODS

A hygiene study of dipping sessions at 20 farms using diazinon based dips was carried out by two experienced occupational hygienists. Observations on the exposure of people to concentrate and dilute dip were recorded throughout each dipping session, together with the other relevant factors including the use and condition of protective clothing. Concentrations of urinary metabolites of diazinon were used to measure actual exposure to OPs. To estimate exposure in the subsequent epidemiological study, an occupational exposure history questionnaire was developed using results from the hygiene study and an empirical exposure model.

RESULTS

In the hygiene study, increased urinary metabolites were associated with the handling of concentrate dip and exposure to dilute dip wash through splashing. Very few dippers wore the recommended protective clothing. The handling of concentrate dip was the principal source of exposure to OPs. Dipping task was used as a surrogate for splashing of dilute dip in retrospective exposure estimation. In the epidemiological study, cumulative exposure to OP sheep dips was highly correlated with the total number of dipping days, but not with age.

CONCLUSIONS

Sheep dip concentrate is the most important source of OP exposure among sheep dippers and estimates of exposure to OPs during routine dipping should take due account of exposure to concentrate dip as well as to the dilute dip wash. The observed use of recommended protective clothing by most subjects was insufficient to allow a proper empirical assessment of its effectiveness.

Kinetic mechanism of acetyl-CoA synthase: steady-state synthesis at variable Co/Co2 pressures

Steady-state initial rates of acetyl-CoA synthesis (upsilon/[E(tot)]) catalyzed by acetyl-CoA synthase from Clostridium thermoaceticum (ACS) were determined at various partial pressures of CO and CO2. When [CO] was varied from 0 to 100 microM in a balance of Ar, rates increased sharply from 0.3 to 100 min(-1). At [CO] > 100 microM, rates declined sharply and eventually stabilized at 10 min(-1) at 980 microM CO. Equivalent experiments carried out in CO2 revealed similar inhibitory behavior and residual activity under saturating [CO]. Plots of upsilon/[E(tot)] vs [CO2] at different fixed inhibitory [CO] revealed that Vmax/[E(tot)] (kcat) decreased with increasing [CO]. Plots of upsilon/[E(tot)] vs [CO2] at different fixed noninhibitory [CO] showed that Vmax/[E(tot)] was insensitive to changes in [CO]. Of eleven candidate mechanisms, the simplest one that fit the data best had the following key features: (a) either CO or CO2 (at a designated reductant level and pH) activate the enzyme (E' + CO right arrow over left arrow E, E' + CO2/2e-/2H+ right arrow over left arrow E); (b) CO and CO2 are both substrates that compete for the same enzyme form (E + CO right arrow over left arrow ECO, E + CO2/2e-/2H+ right arrow over left arrow ECO, and ECO --> E + P); (c) between 3 and 5 molecules of CO bind cooperatively to an enzyme form different from that to which CO2 and substrate CO bind (nCO + ECO right arrow over left arrow (CO)nECO), and this inhibits catalysis; and (d) the residual activity arises from either the (CO)nECO state or a heterogeneous form of the enzyme. Implications of these results, focusing on the roles of CO and CO2 in catalysis, are discussed.

Retrospective collection of exposure data from industry: results from a feasibility study in the United Kingdom

In the United Kingdom the Health and Safety Executive for some years has stored chemical exposure data in their National Exposure Database. However, it has been difficult to persuade industry and other organizations to contribute to this resource. The aim of this project was to devise a cost-effective method of obtaining occupational exposure data on chemicals from U.K. industry and other sources. Five strategies were used to identify data for three different substances: toluene, acrylonitrile, and ethylene oxide. In total, 810 organizations were contacted and over 45 percent responded. However, only 40 had relevant exposure data. Almost equal numbers of acceptable measurements were identified for toluene and acrylonitrile (2,770 and 2,000 respectively) with lesser ethylene oxide data (800). These measurements were drawn from a wide range of industries and are probably representative of measurements made by U.K. industry, although most of the data were from companies employing more than 100 people. During the second phase of the project, more than 3,000 measurements and associated contextual information were collected (499 for toluene, 1,516 for acrylonitrile, and 17 for ethylene oxide, with a further 1,004 measurements for 1 of 27 substances collected simultaneously with one of the above). The costs of identifying and collecting exposure data ranged from ł7 to ł380 per valid measurement, depending on the source of the data. We suggest that, rather than trying to retrospectively collect data, it is likely to be more cost-effective to enlist a number of occupational hygiene consults and industrial organizations to prospectively provide anonymized exposure measurements for inclusion in the Health and Safety Executives National Exposure Database.

Regulation of hexokinase II and glycogen synthase mRNA, protein, and activity in human muscle

Insulin regulates the activity of key enzymes of glucose metabolism in skeletal muscle by altering transcription or translation or by producing activity-altering modifications of preexisting enzyme molecules. Because of the small size of percutaneous muscle biopsies, these phenomena have been difficult to study in humans. This study was performed to determine how physiological hyperinsulinemia regulates the activities of hexokinase (HK), glycogen synthase (GS), and GLUT-4 in human skeletal muscle in vivo. We determined mRNA abundance, protein content, and activities for these proteins in muscle biopsies before and after a hyperinsulinemic clamp in normal subjects. HK I, HK II, GS, and GLUT-4 were expressed in muscle. HK II accounted for 80% of total HK activity and was increased by insulin from a basal value of 2.11 +/- 0.26 to 3.35 +/- 0.47 pmol.min-1.mg protein-1 (P < 0.05); HK I activity was unaffected. Insulin increased GS activity from 3.85 +/- 0.82 to 6.06 +/- 0.49 nmol.min-1.mg-1 (P < 0.01). HK II mRNA was increased 3.3 +/- 1.3-fold (P < 0.05) by insulin infusion. HK I, GS, and GLUT-4 mRNA and protein were unaffected. Because insulin infusion increased HK II but not GS mRNA, we conclude that HK II and GS may be regulated by insulin by different mechanisms in human skeletal muscle.

Therapeutic considerations in patients with refractory neurosarcoidosis

OBJECTIVE

To assess the effectiveness of alternative treatments for patients with refractory neurosarcoidosis.

DESIGN

Nonrandomized, retrospective patient survey.

SETTING

Multicenter, involving patients cared for by their primary physicians and neurologists, and referred for management advice to a neurology consultant.

INTERVENTIONS

Patients were treated with corticosteroids and alternative treatments, including azathioprine, cyclosporine, cyclophosphamide, chlorambucil, methotrexate, and radiation therapy.

RESULTS

Prednisone dosage was successfully tapered to 10 to 20 mg/d without worsening symptoms in 10 (38%) of the 26 patients studied. Six (23%) patients had improved conditions while receiving alternative medication and nine (35%) patients' conditions remained stable with no further progression of their symptoms. Radiotherapy was beneficial for one of three patients. Four (15%) patients did not respond to alternative treatment and died of worsening symptoms or infection. Adverse effects of the alternate medications resolved on discontinuing treatment with the offending agent.

CONCLUSION

Alternative treatment is an effective adjunct to corticosteroid therapy for some patients with refractory neurosarcoidosis. Clinical deterioration may occur despite combined therapy. Choice of alternative therapy should be determined, in part, by its potential adverse effects.

The treatment of neurosarcoidosis with cyclosporine

Six patients with refractory neurosarcoidosis were enrolled in a 12-month open-label trial to investigate the safety and efficacy of cyclosporine therapy. Patients were stabilized on a corticosteroid dose, randomized to a low-dose or high-dose cyclosporine group (with appropriate target whole blood cyclosporine levels) for 6 months, and assessed by prospectively defined studies. The corticosteroid dose was adjusted as clinically tolerated. We found that the corticosteroid dose could be lowered to 30% to 58% of the initial stabilization dose in conjunction with cyclosporine therapy, at the time of maximal clinical and laboratory improvement. However, four patients deteriorated while using corticosteroids and cyclosporine; one of these patients died. At the time of clinical deterioration, the prednisone dose ranged from 6 to 22.5 mg daily (or the equivalent). No serious toxic effects developed from cyclosporine therapy. Cyclosporine treatment is a reasonably safe and effective adjunct to corticosteroid therapy for patients with refractory neurosarcoidosis, although clinical deterioration can occur despite combination therapy.

Enterobius egg granuloma of the vulva and peritoneum: review of the literature

Two cases of Enterobius granuloma containing eggs only are reported. The first case involved the vulva, where no such granuloma has been reported previously. The coexistence of peritoneal granuloma and rectal adenocarcinoma in the second case suggests the possibility of direct penetration of the damaged colonic wall by the parasite, as emphasized by several previous reports of neoplastic involvement and perforation of the intestinal wall in cases of ectopic infections. The diagnostic criteria of Enterobius eggs granuloma, which might be a diagnostic dilemma for pathologists who are not familiar with such criteria, are described herein.

Recurrent Hodgkin's disease in the breast. Diagnosis of a case by fine needle aspiration and immunocytochemistry

Recurrent Hodgkin's disease involving the breast in a 17-year-old girl was diagnosed by fine needle aspiration (FNA) biopsy of a solitary mass that developed one year after "curative" radiation. Benign breast disease and breast carcinoma were ruled out upon cytologic examination of the FNA smears, which contained diagnostic Reed-Sternberg cells and the characteristic polymorphic background elements. Follow-up immunoperoxidase staining for Leu-M1 on destained smears confirmed the diagnosis. Definitive therapeutic measures were initiated after the FNA diagnosis.

Abdominal pain from intestinal duplication

Intestinal duplication is a rare cause of abdominal pain in adults, and may elude diagnosis prior to exploratory laparotomy. We describe a 20-year-old man who had severe abdominal pain with an ileal duplication complicated by a penetrating ulcer within ectopic gastric mucosa.