Electroretinography and suicidal behaviors: a systematic review

BACKGROUND

Electroretinogram (ERG) is one of the tools used to investigate the electrophysiological underpinnings of mental health illnesses and major clinical phenomena (e.g., suicide) to improve their diagnosis and care. While multiple studies have reported specific ERG changes among individuals with suicidal behaviors, we know of no review that has been done to characterize their findings to inform future research.

METHODS

This review included available literature concerning ERG and suicidal behaviors. The paper's first section briefly overviews the theoretical basis of ERG and neurotransmitters involved in suicidal behaviors. The second section describes the findings of a review of studies reporting ERG findings among individuals with suicidal behaviors.

RESULTS

Most reviewed studies reported normal amplitude and implicit time of the a-waves, but the latency in individuals with suicidal behaviors was lower than normal. Additionally, the b-waves amplitude was reduced, but the implicit time and latency were increased. The b-a amplitude ratio and oscillatory potential were decreased.

CONCLUSION

Despite identifying certain ERG correlates with suicidal behaviors in the existing studies, there is a need for adequately powered and methodologically robust studies to advance clinical translation.

Self-harming behaviors and forensic system-related factors: an analysis of the Ontario review board database

BACKGROUND

In Canada, ensuring public safety, and the safety and well-being of accused individuals under the jurisdiction of the provincial review board are very important. While previous studies have reported a significant risk of self-harming behaviors (non-suicidal self-injury and suicide attempt) in forensic psychiatric settings, no large population study has assessed any relationship between forensic system-related factors and self-harming behaviors. A better understanding of these factors can help clinicians implement protective measures to mitigate self-harming behaviors or actions.

METHODS

Using the Ontario Review Board (ORB) database covering 2014-2015 period (n = 1211, mean age = 42.5 ± 13.37 years, males = 86.1%), we analyzed the prevalence and factors associated with self-harming behaviors, emphasizing the characterization of the forensic system-related factors (ORB status, legal status, type of offense, previous criminal history, and victim relationship). The relationships between the forensic system-related factors and self-harming behaviors were explored using five separate logistic regression models, controlling for clinical and sociodemographic characteristics.

RESULTS

Approximately 4% of the individuals in the forensic system over the study period engaged in self-harming behaviors Among the studied patients, individuals determined to be unfit to stand trial and inpatients were significantly more likely to have self-harming behaviors. There was no significant relationship between the type of offence, victim relationship, and previous criminal history with self-harming behavior.

CONCLUSION

Forensic psychiatry inpatients should have close observation, screening, monitoring, and individual tailored management strategies for self-harming behaviors. The findings of this study indicate that forensic system-related factors, especially those that pertain to the status of individuals in the forensic system (i.e., unfit to stand trial and being an inpatient) are more responsible for self-harming behaviors among forensic patients in Ontario.

Evaluation of Perugini score and myocardial mass and voltage abnormalities in transthyretine cardiac amyloidosis

Background

Transthyretine cardiac amyloidosis (TTR-CA) is an emerging treatable disease in cardiology. Severity of TTR infiltration can be assessed by bone scintigraphy with Perugini score, depending on HPD-Tc99M myocardial intensity uptake. Less is known on how Perugini score interplays with routine cardiac structural parameters, especially cardiac mass and voltage.

Aim

To evaluate correlation between Perugini score and myocardial mass and voltage abnormalities in patients with TTR-CA.

Methods

Patients diagnosed with ATTR-CA and addressed to our center for treatment underwent complete evaluation including electrocardiogram (ECG) and transthoracic echocardiography (TTE). Routine electrical and echographic parameters were obtained such as: Sokolow indice (SV1+RV5) in millivolt (mV), PR delay (ms), QRS width (in ms), left ventricular mass (LVM, in grams) and diastolic interventricular septum (dIVS) thickness (in mm). Patients were classified in three categories according to Perugini score: I (cardiac uptake < chest bones), II (cardiac uptake = chest bones) and III (cardiac uptake > bones). Main end-point were LVM and Voltage/Mass ratio (VMR) variations, depending on Perugini score.

Results

Among the 17 patients included, 14 were male (82.4%) and mean age was 82±8 years old. On ECG, 6 patients (35.3%) had permanent atrial fibrillation (AF). Mean voltage according to Sokolow index, mean PR delay and mean QRS width were respectively 1.5±0.5 mV, 212±54 ms and 113±19 ms. On TTE, mean LVM and mean dIVS width were respectively 333±98 g (188±55 g/m2) and 19±4 mm. Mean voltage/mass ratio (VMR) was 0.48±0.26 uV/g (see table). On bone scintigraphy, 3 patients were scored with Perugini I (17.6%), 4 with Perugini II (23.5%) and 10 with Perugini III (58.8%). According to Pearson test, there was a strong correlation between Perrugini score and LVM (r=+0.56, p=0.03) (graph A), and a strong negative correlation between Perrugini score and VMR (r=−0.70, p=0.003) (graph B). There were a trend for correlation between Perugini score and Voltage according to Sokolow (r=−0.46, p=0.07) and between Perugini score and dIVS width (r=0.49, p=0.07).

Conclusion

In TTR-CA patients, Perugini score appears to strongly correlate with left ventricle mass and voltage. Larger scale studies are needed to confirm these results.

Funding Acknowledgement

Type of funding sources: None. ECG and TEE trends according to PeruginiCardiac mass and voltage with Perugini

Differential effects of high fat diet and diet-induced obesity on skeletal acquisition in female C57BL/6J vs. FVB/NJ Mice

The effects of obesity on bone metabolism are complex, and may be mediated by consumption of a high fat diet and/or by obesity-induced metabolic dysregulation. To test the hypothesis that both high fat (HF) diet and diet-induced metabolic disease independently decrease skeletal acquisition, we compared effects of HF diet on bone mass and microarchitecture in two mouse strains: diet-induced obesity (DIO)-susceptible C57BL/6J (B6) and DIO-resistant FVB/NJ (FVB). At 3 wks of age we weaned 120 female FVB and B6 mice onto normal (N, 10% Kcal/fat) or HF diet (45% Kcal/fat) and euthanized them at 6, 12 and 20 weeks of age (N = 10/grp). Outcomes included body mass; percent fat and whole-body bone mineral density (WBBMD, g/cm2) via DXA; cortical and trabecular bone architecture at the midshaft and distal femur via μCT; and marrow adiposity via histomorphometry. In FVB HF, body mass, percent body fat, WBBMD and marrow adiposity did not differ vs. N, but trabecular bone mass was lower at 6 wks of age only (p < 0.05), cortical bone geometric properties were lower at 12 wks only, and bone strength was lower at 20 wks of age only in HF vs. N (p < 0.05). In contrast, B6 HF had higher body mass, percent body fat, and leptin vs. N. B6 HF also had higher WBBMD (p < 0.05) at 9 and 12 wks of age but lower distal femur trabecular bone mass at 12 wks of age, and lower body mass-adjusted cortical bone properties at 20 wks of age compared to N (p < 0.05). Marrow adiposity was also markedly higher in B6 HF vs. N. Overall, HF diet negatively affected bone mass in both strains, but was more deleterious to trabecular bone microarchitecture and marrow adiposity in B6 than in FVB mice. These data suggest that in addition to fat consumption itself, the metabolic response to high fat diet independently alters skeletal acquisition in obesity.

Outcome of surgical management of stress fractures in high demand individuals

Stress fractures represent one-fifth of overuse injuries in sport. Successful healing of stress fractures in high demand individuals is important to prevent complications upon early return to activity. This article reviews the literature on outcomes of surgical management of stress fractures in high demand individuals. An online literature search was carried out for articles published up to and including January 2017. Twenty five papers were reviewed. In the majority of studies, no complications were reported, clinical and radiographic healing was achieved, and patients returned to their premorbid level of activity. Current literature suggests good outcomes after surgical management of stress fractures in high demand individuals, particularly those in whom conservative treatment has failed. Further studies comparing surgical techniques are necessary to demonstrate the most efficacious.

[Faintness in emergency departments is frequent, benign but expensive: An epidemiologic study of hospitalization's risk factors to reduce overcrowdings of emergency departments]

INTRODUCTION

We assessed (i) the frequency of consultations for faintness in the Emergency department (ED) of a University hospital centre (UHC), (ii) clinical epidemiology and (iii) cost of faintness, taking a particular interest into the determining risk factors for hospitalization.

METHODS

This epidemiological study has been conducted retrospectively, from data obtained for every patient having consulted for faintness in ED of Reims UHC (01/01/12-03/31/12). Every medical record was classified as syncope/lipothymia/brief consciousness loss on one hand and as syncope according to the definition of the French Health High Authority (FHHA).

RESULTS

Three hundred and forty-one patients out of 5953 (5.7%) were referred for faintness during the study period. Medical records were analysed for 296 patients. Sixty-two point eight percent were women, with a median age of 43years. Physical examination was normal for 57% of patients. For 48% of cases, there was no complete consciousness loss thus corresponding to lipothymia, which is not taken into account by the FHHA definition. Median length of stay in the ED was 4hours and 67 patients (22.6%) were hospitalized. Minimal estimated cost was 280,000 euros. Risk factors independently associated with hospitalization were age≥60 and complete consciousness loss unlike predisposing circumstances to vagal hypertonia.

CONCLUSION

Age≥60 and complete consciousness loss seemed to be associated with hospitalization.

Disseminated Mycobacterium tuberculosis infection due to interferon gamma deficiency. Response to replacement therapy

The case of a previously healthy HIV seronegative woman with disseminated Mycobacterium tuberculosis infection and markedly reduced interferon gamma production is reported here. Complete healing of her disseminated lesions was seen only after addition of subcutaneous interferon gamma to her tuberculosis treatment.

Hormonal impact of the 17alpha-hydroxylase/C(17,20)-lyase inhibitor abiraterone acetate (CB7630) in patients with prostate cancer

A series of three dose escalating studies were conducted to investigate the ability of the 17α-hydroxylase/C_17,20-lyase inhibitor abiraterone acetate, to cause maximum suppression of testosterone synthesis when delivered to castrate and noncastrate males with prostate cancer. Study A was a single dose study in castrate males. Study B was a single dose study in noncastrate males and study C was a multiple dose study in noncastrate males. The drug was given orally in a once-daily dose and blood samples taken to assess pharmacokinetic (PK) parameters and hormone levels in all patients. The study drug was well tolerated with some variability in PKs. Suppression of testosterone levels to <0.14 nmol l⁻¹ was seen in four out of six castrate males treated with a single dose of 500 mg. At 800 mg given days 1–12 in noncastrate males, target suppression was achieved in three out of three patients, but a two- to three-fold increase of Luteinising Hormone (LH) levels in two out of three patients overcame suppression within 3 days. All patients in the multiple dose study developed an abnormal response to a short Synacthen test by day 11, although baseline cortisol levels remained normal. This is the first report of the use of a specific 17α-hydroxylase/_17,20-lyase inhibitor in humans. Repeated treatment of men with intact gonadal function with abiraterone acetate at a dose of 800 mg can successfully suppress testosterone levels to the castrate range. However, this level of suppression may not be sustained in all patients due to compensatory hypersecretion of LH. The enhanced testosterone suppression achieved in castrate men merits further clinical study as a second-line hormonal treatment for prostate cancer. Adrenocortical suppression may necessitate concomitant administration of replacement glucocorticoid.

A phase I trial of antibody directed enzyme prodrug therapy (ADEPT) in patients with advanced colorectal carcinoma or other CEA producing tumours

Antibody-directed enzyme prodrug therapy is a targeted therapy in which a prodrug is activated selectively at the tumour site by an enzyme, which has been targeted to the tumour by an antibody (antibody-enzyme conjugate). Previous clinical trials have shown evidence of tumour response, however, the activated drug had a long half-life, which resulted in dose-limiting myelosuppression. Also, the targeting system, although giving high tumour to blood ratios of antibody-enzyme conjugate (10 000 : 1) required administration of a clearing antibody in addition to the antibody-enzyme conjugate. The purpose of this current study therefore was to attempt tumour targeting of the antibody-enzyme conjugate without the clearing antibody, and to investigate a new prodrug (bis-iodo phenol mustard, ZD2767P) whose activated form is highly potent and has a short half-life. Twenty-seven patients were treated with antibody-directed enzyme prodrug therapy using A5CP antibody-enzyme conjugate and ZD2767P prodrug, in a dose-escalating phase I trial. The maximum tolerated dose of ZD2767P was reached at 15.5 mg m(-2)x three administrations with a serum carboxypeptidase G2 level of 0.05 U ml(-1). Myelosuppression limited dose escalation. Other toxicities were mild. Patients' quality of life was not adversely affected during the trial as assessed by the measures used. There were no clinical or radiological responses seen in the study, but three patients had stable disease at day 56. Human anti-mouse antibody and human anti-carboxypeptidase G2 antibody were produced in response to the antibody enzyme conjugate (A5CP). The antibody-enzyme conjugate localisation data (carboxypeptidase G2 enzyme levels by HPLC on tumour and normal tissue samples, and gamma camera analysis of I-131 radiolabelled conjugate) are consistent with inadequate tumour localisation (median tumour: normal tissue ratios of antibody-enzyme conjugate of less than 1). A clearance system is therefore desirable with this antibody-enzyme conjugate or a more efficient targeting system is required. ZD2767P was shown to clear rapidly from the circulation and activated drug was not measurable in the blood. ZD2767P has potential for use in future antibody-directed enzyme prodrug therapy systems.

A phase II trial of bryostatin 1 in patients with non-Hodgkin's lymphoma

Bryostatin 1 is a naturally occurring macrocyclic lactone with promising antitumour and immunomodulatory function in preclinical and phase I clinical investigations. In this phase II study, 17 patients with progressive non-Hodgkin's lymphoma of indolent type (NHL), previously treated with chemotherapy, received a median of 6 (range 1-9) intravenous infusions of 25 microg/m(2) bryostatin 1 given once weekly over 24 hours. In 14 evaluable patients no responses were seen. Stable disease was attained in one patient for 9 months. The principal toxicities were myalgia and phlebitis. Treatment was discontinued early because of toxicity alone (phlebitis) in 2 patients, toxicity in addition to progressive disease in 3 patients (myalgia and phlebitis n = 2; thrombocytopenia n = 1) and progressive disease in 5 patients. The results fail to demonstrate efficacy of this regimen of bryostatin 1 in the treatment of NHL. In light of preclinical data that demonstrate synergy between bryostatin 1 and several cytotoxic agents and cytokines, clinical studies to investigate bryostatin 1 in combination are warranted. We also present data to demonstrate that central venous lines may be used in future studies to avoid phlebitis.

Evaluation of docking/scoring approaches: a comparative study based on MMP3 inhibitors

An increasing number of docking/scoring programs are available that use different sampling and scoring algorithms. A reliable scoring function is the crucial element of such approaches. Comparative studies are needed to evaluate their current capabilities. DOCK4 with force field and PMF scoring as well as FlexX were used to evaluate the predictive power of these docking/scoring approaches to identify the correct binding mode of 61 MMP-3 inhibitors in a crystal structure of stromelysin and also to rank them according to their different binding affinities. It was found that DOCK4/PMF scoring performs significantly better than FlexX and DOCK4/FF in both ranking ligands and predicting their binding modes. Most notably, DOCK4/PMF was the only scoring/docking approach that found a significant correlation between binding affinity and predicted score of the docked inhibitors. However, comparing only those cases where the correct binding mode was identified (scoring highest among sampled poses), FlexX showed the best 'fine tuning' (lowest rmsd) in predicted binding modes. The results suggest that not so much the sampling procedure but rather the scoring function is the crucial element of a docking program.

Ovarian function during use of Nestorone(R) subdermal implants

Nestorone(R) progestin (NES) is a potent 19-nor-progesterone derivative which is biologically inactive when administered orally; however, it is an excellent option for implant contraception. The objective of this study was to evaluate ovarian function during use of either one 4-cm or two 3-cm NES implants for 24 months. A total of 60 volunteers were enrolled in each dose group. Vaginal ultrasound (VUS) and blood sampling for determinations of estradiol (E(2)), progesterone (P) and NES serum levels were carried out twice a week for 6 consecutive weeks, beginning in months 1, 6, 12, 18, and 24 of implant use. Serum levels of NES declined with time, with a more pronounced decrease during the first 18 months of implant use; thereafter, NES levels remained stable until the end of the study at 24 months. Luteal activity was very infrequent during the first year of use (<3%) but increased during the second year, occurring in 27% and 35% of the sampling periods in the 1-implant group, and 2% and 16% of the sampling periods in the 2-implant group, at months 18 and 24 of use, respectively. No luteal activity was observed with NES levels above 80 pmol/L. Serum P levels in periods of luteal activity were significantly lower than those of controls. Persistent anovulatory follicles were the most common VUS finding and this was associated with E(2) levels that remained within the normal range (101-1500 pmol/L) in the majority of the sampling periods studied. Considering that a single implant offers advantage for insertion and removal, a new single NES implant is being developed with a slightly higher release rate, to reduce effectively the incidence of ovulation and provide a greater margin of safety beyond 2 years.

The U.S. health data privacy debate. Will there be comprehension before closure?

After 25 years of debate about privacy of automated personal health data, the U.S. Congress has set a deadline of August 1999 for enacting health information privacy legislation. The urgency to establish national policy in the United States re-emerges with implementation of a 1996 law mandating a unique identifier for each participant in the U.S. medical care system and the use of a uniform electronic data set for all health information transmitted in financial and administrative transactions. The impact of electronic data storage and transmittal on privacy, health outcomes, and medical care is unclear. A three-step analytic scheme can clarify the issues in the policy debate and for future assessment. The first step is intended to elicit, for the first time, a precise, accurate, and reproducible description of personal health data transactions and chains of transactions, independent of the policy preferences of any interested party. The second step allows the reader to analyze these transactions according to who benefits first and foremost from each. This scrutiny clarifies the reasons why parties to the debate tend to disagree. The third step characterizes how Congress is likely to perceive the policy process and consider its options before enacting any particular set of compromises. Understanding the policy deliberations and potential effects of evolving information technologies and new national privacy rules should aid assessment of results.

Brundtland's World Health Organization: a test case for United Nations reform

Gro Harlem Brundtland, who became Director General of the World Health Organization in July 1998, has created a small revolution at the WHO headquarters in Geneva. She is in the process of changing how WHO works, how it interacts with other parts of the United Nations system, and how it enlists ministries, whole governments, universities, and other private organizations to improve health in the world. Here, the Editor describes the reorganization, the new people and resources, and prospects for setting a precedent in United Nations reform.

Havana revisited

Images

How organized medical care can advance public health

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Mechanism of action and clinical effects of antiprogestins on the non-pregnant uterus

Considerable progress has been made in elucidating the mechanism of action of antiprogestins. The biological response to a progesterone antagonist depends on many factors. The usual effect is that of an antagonist, but progesterone agnostic or even antioestrogenic or oestrogenic effects have also been observed. The present review focuses on the clinical applications of antiprogestins in the non-pregnant uterus. Whereas high doses of antiprogestins block ovulation, low doses impair endometrial development without affecting ovulation, hormonal levels or bleeding patterns Indeed, the endometrium is the tissue which is the most sensitive to antiprogestins. The effect of antiprogestins is to produce a delay in endometrial maturation and to postpone the appearance of the implantation window. This concept of 'endometrial contraception' requires further testing in humans, although the principle has been proven in monkeys. In contrast to the low doses of mifepristone which delay endometrial maturation, a minimum dose of 50 mg is required to produce endometrial bleeding. Late luteal phase antiprogestin administration does not disturb ovulation, hormonal levels or bleeding patterns. This has clinical application, and mifepristone has been used together with prostaglandins in women with delayed menses to successfully prevent implantation. Mifepristone has also been shown to be an effective post-coital agent. However, when used on a regular basis once monthly at the end of the cycle as a potential contraceptive, the results are disappointing. Because of their antiproliferative and anti-oestrogenic effects on the endometrium, antiprogestins are also used in the treatment of oestrogen-dependent conditions such as endometriosis and fibromyomas. In humans, chronic administration of high doses of antiprogestins has on rare occasions been associated with endometrial hyperplasia, presumably a consequence of unopposed oestrogen activity. This does not occur with low doses (1 mg daily for 5 months).

Selections from current literature: minor depression

The term "minor depression" has had several accepted definitions with differing diagnostic criteria. A review of papers published during the period 1991-1996, in which minor depression was a component of the study, demonstrates the extent of these differences. The heterogeneity of definitions of minor depression has been an obstacle to research on a mental disorder that appears to have a high prevalence and causes significant functional disability. As a result of these differing definitions, there is uncertainty about its natural history and prevalence, and whether therapy is beneficial. Agreement on a standard definition is necessary for investigations that are required to describe adequately these components of minor depression. This paper details the variety of definitions of minor depression and suggests use of the research diagnostic criteria published in the Diagnostic and Statistical Manual, fourth edition (DSM-IV) in future research.

Early pregnancy termination with mifepristone and misoprostol in the United States

BACKGROUND

Mifepristone and a prostaglandin have been used successfully to terminate pregnancy in Europe and China. We report the results of a large U.S. study of mifepristone and misoprostol in women with pregnancies of up to nine weeks' duration.

METHODS

We administered 600 mg of mifepristone and then 400 microg of misoprostol two days later to 2121 women seeking termination of their pregnancies at 17 centers. The women were observed for four hours after the administration of misoprostol and returned on day 15 for final assessment.

RESULTS

Two thousand fifteen women completed the final assessment. Among them, pregnancy was terminated in 762 of the 827 women pregnant for < or =49 days (92 percent), 563 of the 678 women pregnant for 50 to 56 days (83 percent), and 395 of the 510 women pregnant for 57 to 63 days (77 percent) (P<0.001). Termination occurred within 4 hours after the administration of misoprostol in 49 percent of the women and within 24 hours in 75 percent. Failures, defined as cases requiring surgical intervention for medical reasons or because the patient requested it, the abortion was incomplete, or the pregnancy was ongoing, increased with increasing duration of pregnancy. The largest increase was in failures representing ongoing pregnancy, which increased from 1 percent in the < or =49-days group to 9 percent in the 57-to-63-days group (P<0.001). Abdominal pain, nausea, vomiting, diarrhea, and vaginal bleeding also increased with advancing gestational age. Two percent of the women in the < or =49-days group, as compared with 4 percent in each of the other two groups, were hospitalized, underwent surgical interventions, and received intravenous fluids (P=0.008).

CONCLUSIONS

This mifepristone-misoprostol regimen is effective in terminating pregnancies, especially in women with pregnancies of 49 days' duration or less.