High-School Football and Midlife Brain Health Problems

OBJECTIVE

To examine whether middle-aged men who played high-school football experience worse mental health or cognitive functioning than men who did not play high-school football.

DESIGN

Cross-sectional cohort study.

SETTING

Online survey completed remotely.

PARTICIPANTS

A total of 435 men between the ages of 35 and 55 completed the study, of whom 407 were included in the analyses after excluding participants who answered embedded validity items incorrectly (n = 16), played semiprofessional football (n = 2), or experienced a recent concussion (n = 10).

ASSESSMENT OF RISK FACTORS

Self-reported high school football participation, compared with those who played contact sports, noncontact sports, and no sports.

MAIN OUTCOME MEASURES

A lifetime history of depression or anxiety; mental health or cognitive problems in the past year; current depression symptoms, and post-concussion-like symptoms.

RESULTS

Middle-aged men who played high-school football did not have a higher prevalence of being prescribed medication for anxiety or depression or receiving treatment from a mental health professional. Similarly, there were no significant differences between groups on the rates in which they endorsed depression, anxiety, anger, concentration problems, memory problems, headaches, migraines, neck or back pain, or chronic pain over the past year. A greater proportion of those who played football reported sleep problems over the past year and reported being prescribed medication for chronic pain and for headaches.

CONCLUSIONS

Men who played high-school football did not report worse brain health compared with those who played other contact sports, noncontact sports, or did not participate in sports during high school.

Insulinoma in an adolescent female with weight loss: a case report and literature review on pediatric insulinomas

Summary

Insulinomas are a rare cause of persistent hypoglycemia in a previously healthy child. In addition to symptoms of hypoglycemia, individuals with insulinomas usually present with a history of incessant caloric intake and weight gain due to a constant need to counter hypoglycemia. In addition to an extensive review of the literature, we report the first case of an insulinoma coexisting with reduced appetite secondary to anorexia nervosa in an adolescent female.

Learning points

Eliciting a detailed family history is important in hypoglycemia cases. Obtaining a thorough dietary intake, weight history, and menstrual cycles (in females) and considering a psychiatric consultation for an eating disorder when indicated. Although rare in the pediatric population, multiple endocrine neoplasia type 1 syndrome should be considered in the evaluation of children and adolescents with hypoglycemia who also have a family history of pituitary, pancreatic, and/or parathyroid endocrinopathies.

A rare case of 46,XX gonadal dysgenesis, Mayer-Rokitansky-Kuster-Hauser syndrome, pituitary and thyroid hypoplasia

SUMMARY

Mayer-Rokitansky-Kuster-Hauser syndrome is characterized by congenital absence or hypoplasia of the uterus and upper two-thirds of the vagina in both phenotypically and karyotypically normal females with functional ovaries, whereas gonadal dysgenesis is a primary ovarian defect in otherwise normal 46,XX females. An association between these two conditions is extremely rare. We report a 21-year-old female presented with primary amenorrhea and undeveloped secondary sexual characteristics. The karyotype was 46,XX and the hormonal profile revealed hypothyroidism and hypogonadotropic hypogonadism. Pelvic MRI showed class I Mullerian duct anomaly with ovarian dysgenesis. Ultrasound showed bilateral thyroid hypoplasia and brain MRI suggested anterior pituitary hypoplasia. Levothyroxine and hormone replacement therapy were started.

LEARNING POINTS

The simultaneous presentation of 46,XX gonadal dysgenesis, Mayer-Rokitansky-Kuster-Hauser syndrome, hypothyroidism, and pituitary hypoplasia is a Possibility. Extensive evaluation should be made when a patient presents with one or more of these features. The diagnosis imposes a significant psychological burden on patients and adequate counseling should be provided. Hormone replacement therapy remains the only therapeutic option for the development of secondary sexual characteristics and the prevention of osteoporosis.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Extreme hyponatraemia due to primary polydipsia and quetiapine-induced SIAD

SUMMARY

Hyponatraemia is the most common electrolyte disturbance in hospitalised patients and is associated with numerous adverse outcomes. Patients with schizophrenia are particularly susceptible to hyponatraemia, in part due to the close association between this condition and primary polydipsia. We report the case of a 57-year-old woman with schizophrenia and primary polydipsia who was receiving inpatient psychiatric care. She became increasingly confused, had multiple episodes of vomiting, and collapsed 1 week after being commenced on quetiapine 300 mg. On examination, she was hypertensive and her Glasgow coma scale was nine. She had a fixed gaze palsy and a rigid, flexed posture. Investigations revealed extreme hyponatraemia with a serum sodium of 97 mmol/L. A CT brain demonstrated diffused cerebral oedema with sulcal and ventricular effacement. A urine sodium and serum osmolality were consistent with SIAD, which was stimulated by the introduction of quetiapine. The antidiuretic effect of vasopressin limited the kidney's ability to excrete free water in response to the patients' excessive water intake, resulting in extreme, dilutional hyponatraemia. The patient was treated with two 100 mL boluses of hypertonic 3% saline but deteriorated further and required intubation. She had a complicated ICU course but went on to make a full neurological recovery. This is one of the lowest sodium levels attributed to primary polydipsia or second-generation antipsychotics reported in the literature.

LEARNING POINTS

The combination of primary polydipsia and SIAD can lead to a life-threatening, extreme hyponatraemia. SIAD is an uncommon side effect of second-generation anti-psychotics. Serum sodium should be monitored in patients with primary polydipsia when commencing or adjusting psychotropic medications. Symptomatic hyponatraemia is a medical emergency that requires treatment with boluses of hypertonic 3% saline. A serum sodium of less than 105 mmol/L is associated with an increased risk of osmotic demyelination syndrome, therefore the correction should not exceed 8 mmol/L over 24 h.

Factitious Cushing's syndrome, hypopituitarism, and self-provoked skin lesions: when the skin mirrors the soul

SUMMARY

Factitious Cushing's syndrome (CS) is a very rare form of Münchausen syndrome. Its presentation and course are extremely heterogeneous, and diagnosis is generally challenging. We report the case of a 52-year-old woman who was initially investigated because of the occurrence of cushingoid features. Nevertheless, endocrine work-up showed very low morning plasma ACTH and serum cortisol levels. In addition, it also demonstrated central hypopituitarism and hypogonadotropic hypogonadism. Head MRI showed a small pituitary mass. Based on these results, and probably overlooking the initial clinical suspicion, general practitioner (GP) referred the patient to our Endocrine Unit for hypopituitarism. At inspection, moon face, central obesity, and bruising were evident. Multiple ulcerative skin lesions were also concentrated in the right arm and leg. Dermatology evaluation suggested that the lesions were self-provoked. For several days, the patient denied the assumption of corticosteroids, but we finally discovered that the GP' nurse had prescribed betamethasone without the GP's knowledge for about 2 years. In conclusion, the surreptitious assumption of corticosteroids is very rare, but the physicians should be aware that pituitary function could be impaired by high doses of corticosteroids, mimicking hypopituitarism. In these patients, a multidisciplinary approach and environmental investigation can be useful to diagnose factitious CS.

LEARNING POINTS

Surreptitious assumption of corticosteroids can cause heterogeneous presentation, ranging from Cushing's syndrome to multiple hypopituitarism. Suppression of ACTH and cortisol levels in a patient with cushingoid features firstly suggests surreptitious assumption of corticosteroids. A multidisciplinary approach can be extremely useful in patients with suspected factitious Cushing's syndrome. Sometimes, to prove surreptitious assumption of corticosteroids needs environmental investigation.

Successful medical management of insulinoma with diazoxide for 27 years

SUMMARY

Despite improvements in localisation techniques and surgical advances, some patients with insulinoma will not be cured by surgery or may not be suitable for surgery. Medical management with diazoxide is an option for such cases. This case report details 27 years of successful management of insulinoma using diazoxide. It has been effective and safe, with only minor adverse effects.

LEARNING POINTS

Long term diazoxide use can be a safe, effective option for insulinoma when it cannot be localised or removed surgically. Common adverse effects include peripheral oedema, hyperuricaemia, and hirsutism. 68Ga-NOTA-exendin-4 PET/CT scan should be considered for insulinoma localisation when other modalities have been unhelpful.

Is donating a kidney to a friend bad for your marriage?

Studies have shown that kidney donation to a spouse has a positive impact on marriage. This study was done to evaluate the impact on marriage when donation occurs to someone other than the spouse. Two groups of donors from our centre who donated around the same period were studied: donation to a spouse (spouse donor (SD)) or to someone other than the spouse (non-spouse donor (ND)). A survey, the Revised Dyadic Adjustment Scale, was used to evaluate the effect of donation on the marriage. This tool consists of 14 questions that measure how satisfying and stable the relationship is. The results showed equal or better marriage scores in the ND group compared with the SD group. The NDs scored higher on two questions, one regarding agreement or disagreement on career choices (P = 0.05) and the other regarding the frequency of having stimulating exchanges of ideas with one's spouse (P = 0.02). With the highest possible total score of 69, NDs scored 53.4 and SDs scored 47.7 (P = 0.16). Scores of 47 and below indicate marital distress. In one final additional question, 97% of NDs reported 'no change or good effect' on the marriage, similar to 91% for SDs (P = 0.46). This is the first study to evaluate the effect of kidney donation on the state of marriage when the spouse is not the recipient. It appears that marriage is not impacted negatively when kidney donation occurs to someone other than the spouse.

Psychosocial factors in people with chronic kidney disease prior to renal replacement therapy

Increasing evidence implicates psychosocial factors including depression, anxiety, perceived social support and health-related quality of life in the pathophysiology of various chronic diseases. Research examining the psychosocial aspects of kidney disease has focussed predominantly on depressive disorders in dialysis patients where they are independently associated with increased risk of mortality and poor health-related quality of life. In contrast, studies examining the influence of psychosocial factors in people with chronic kidney disease (CKD) prior to the initiation of renal replacement therapy are sparse. Limited data indicate that clinical depression and depressive symptoms are common and may independently predict progression to dialysis, hospitalization and death. In contrast, the influence of anxiety disorders, lower perceived social support and impaired health-related quality of life on the clinical course of CKD have received little attention. Large-scale prospective cohort studies are needed to clarify the burden and prognostic impact of these factors in this vulnerable population. Given the escalating burden of CKD worldwide examining the role of these potentially modifiable risk factors is crucial. Identifying and implementing targeted interventions in order to prevent or delay the progression of CKD and improve quality of life will be a major challenge.

Depression in patients with hypertrophic cardiomyopathy: is there any relation with the risk factors for sudden death?

OBJECTIVES

The aim of this study was to investigate whether depressive symptoms are related to the risk factors for sudden death in patients with hypertrophic cardiomyopathy (HCM).

DESIGN

121 patients diagnosed as having HCM were assessed for depressive symptomatology using the Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale (CES-D) and followed up for a period of 2 years. For the interview, the authors used the Structured Clinical Interview for DSM-III/DSM-III-R. A multidimensional longitudinal study was carried out with both somatic and psychological symptoms and signs taken into consideration. SPSS was used for the statistical analysis.

RESULTS

(1) Patients with HCM are more depressed than the general population. (2) There is no positive correlation between the occurrence of depressive symptoms and the risk factors for sudden death in patients with HCM. (3) Patients at high risk for sudden death are not more depressed than the others. (4) Time from diagnosis of the cardiac disease is not related to the presence and severity of depressive symptoms.

CONCLUSIONS

Patients with HCM are more depressed than the general population. The authors suggest that depressive symptoms and risk factors for sudden death in these patients are not related. It is important to screen for mood disorders in this patient population in order to provide an early diagnosis and treatment of the psychiatric disease.