Level of cognitive function is usually conceptualized as a feature of organic psychiatric disorders. Classically, its assessment is part of the mental status examination. Standardized tests, such as the Folstein battery, are used to screen for organic disorders by measuring level and possible impairment of cognitive function through the stipulation of cutoff points. However, contemporary definitions of psychiatric disorders do not embrace such a categorical view of cognitive function. It is important to measure the level of cognitive function in all types of psychiatric disorders in relation to demographic characteristics. Consequently, it is better to view cognitive function as a continuous variable. The Cognitive Function Inventory (CFI), which can also yield a Folstein score, was used to assess cognition in patients diagnosed as having nonorganic psychiatric disorders. A number of different parameters of cognitive function are examined. Differences associated with demographic background and type of disorder are reported. The implications of these results are discussed.

Adjustment Disorders↗

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Effects of anti-epileptic drug therapy on bone mineral density in ambulatory epileptic children.

In order to assess the bone changes in the subjects receiving anti-epileptic drugs (AEDs), bone mineral densities (BMDs) of the arms, legs, ribs, pelvis, spine, and the whole body were scanned in 78 epileptic children and in 78 controls using dual photon absorptiometry. The study subjects were classified according to the duration of the monotherapy with phenobarbital (PB) or phenytoin (PHT); those who received AEDs for less than 12 months as Group I, for 13-23 months as Group II, and for 24 months as Group III. Group III was subclassified according to the kind of AEDs administered, into those receiving PB as Group IIIp, and those receiving PHT as Group IIId. There was no significant differences in the BMDs of each area, when compared to each control in Groups I and II. In Group III, there were significant differences in ribs and spine, according to the duration of administration. In Group IIIp, there was a significant difference in ribs and spine, and, in Group IIId, there was a significant difference in most of the areas. These results show that the measurement of BMDs in the ribs and spine is necessary for the early detection of subtle bone loss, and it is recommended that vitamin D be administered to children with epilepsy receiving AEDs over 24 months.

Absorptiometry, Photon↗

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Organ heavy-metal accumulation during parenteral nutrition is associated with pathologic abnormalities in rats.

OBJECTIVES: Metabolic bone disease, hepatic abnormalities, splenic insufficiency, and nephropathy have been associated with long-term total parenteral nutrition (TPN). We determined the heavy-metal contamination in TPN solutions and investigated whether it was associated with organ deposition and pathologic organ damage. METHODS: Five representative TPN solutions (two adult standard solutions, one renal solution, and one standard pediatric solution to reflect clinical practice) and 28 TPN components were analyzed with inductively coupled plasma mass spectrometry. Twenty-six male Fisher 344 rats were assigned to two groups (chow/NaCl = 8 and TPN = 18). TPN or NaCl was infused at a rate of 50 mL/d. After 14 d, serum, femurs, spine, liver, kidneys, brain, spleen, and testes were analyzed for heavy-metal deposition by using inductively coupled plasma mass spectrometry. Tissues were fixed in formalin, sectioned, and stained with hematoxylin and eosin, periodic acid Schiff, and Masson's trichrome stain. Kidneys were fixed in gluteraldehyde for ultrastructural examination with scanning electron microscopy. RESULTS: The predominant sources of contaminants in TPN were amino acids (Al, As, Cr, Ge, Pb, Sn), dextrose (As, Ba, Cr, Sn), Ca gluconate (Al), K2PO4 (Al), lipid emulsion (As, Sn), and vitamins (As). Significant variations in the level of contamination depended on TPN formulation and brand of constituents. In the kidney, Pb, Cr, and Mn concentrations were greater than in controls, although there was no correlation with serum creatinine. Hepatic Cr and Pb concentrations were greater in TPN rats, although there was no correlation with serum aspartate aminotransferase or total bilirubin. Splenic Ba, Cr, Ge, Pb, Mn, and Sn concentrations were greater in TPN rats. Only serum Cr concentration was significantly correlated with splenic concentration (r = 0.46, P = 0.04). Brain and serum Ba concentrations were significantly correlated (r = 0.60, P = 0.007). No significant correlations were observed between any other metal in serum and that metal's respective organ concentration. No increase in heavy-metal accumulation was seen in the femur, spine, or testis. There were no significant depositions of As, Cd, Hg, St, or V in any of the organs examined. Serum Al and Cr concentrations were significantly increased in TPN rats, although there was no correlation with tissue concentrations. No significant increases in heavy-metal concentrations in tissue or plasma were observed for any of the other metals measurable by inductively coupled plasma mass spectrometry. Histologically in the TPN group, 50% of the rats had mild to moderate hepatic steatosis and 33% to 50% developed renal morphologic abnormalities; brains and spleens remained histologically normal. CONCLUSIONS: We found significant heavy-metal contamination of TPN solutions, and this contamination can lead to organ deposition and subsequent histologic abnormalities.

Animals↗

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Clinical implications of antineutrophil cytoplasmic antibody test in lupus nephritis.

To elucidate the prevalence and clinical implications of antineutrophil cytoplasmic antibody (ANCA) in lupus nephritis (LN), we examined ANCA by indirect immunofluorescence and by ELISA against antilactoferrin (anti-LF) and antimyeloperoxidase (anti-MPO) antibody. To discriminate perinuclear ANCA (pANCA) with antinuclear antibody (ANA), all the ANCA-positive sera were tested again after incubating patients' sera with single-stranded (SS) and double-stranded (ds) DNA. These results were compared with clinicopathologic manifestations and clinical courses of LN. ANCA was positive in 19 (37.3%) of 51 LN patients. Among these LN patients, 3 had cytoplasmic ANCA (cANCA) and 16 had pANCA. ANCA was not found in 8 SLE patients without nephritis and 30 normal controls. The presence of ANCA, particularly pANCA, was associated with the presence of nephritis (18/51 cases vs. 0/8 cases, p < 0.05), especially with diffuse proliferative lupus nephritis, WHO class IV (17/18 cases vs. 21/31 cases, p < 0.05) as well as the presence of anti-dsDNA antibody (17/19 cases vs. 18/30 cases, p < 0.05). Patients with ANCA frequently had deterioration of renal function (3/16 vs. 0/26 cases). Anti-LF antibody was positive in 13 patients. Among those, 12 patients had nephritis. Five patients with anti-LF antibody did not have ANCA, but 7 had pANCA, and 1 had cANCA. Patients with anti-LF antibody had lower initial creatinine levels than those without it [serum creatinine (mg/dl): 0.78 (0.6-1.0) vs. 1.43 (0.5-5.0), p < 0.05]. Anti-MPO antibody was positive in only 1 patient, suggesting that MPO is a rare antigen for ANCA in LN.

Adult↗

PubMedDate not supplied

Secondary polycythemia associated with idiopathic membranous nephropathy.

A 58-year-old male patient had secondary polycythemia associated with idiopathic nephrotic syndrome. The renal biopsy revealed membranous nephropathy, and the bone marrow biopsy disclosed hypercellular marrow with mild panhyperplasia. The concentration of serum erythropoietin was 8.5 mU/ml. The erythrocytosis was characterized by an increased red cell volume (40.2 ml/kg) and normal arterial oxygen saturation. There were no associated lesions that could induce secondary polycythemia, except the biopsy-proven membranous nephropathy. He was treated with prednisolone and cyclophosphamide, and the nephrotic syndrome was partially remitted after 6 weeks. With partial remission of nephrotic syndrome, the erythrocytosis was resolved. This case illustrates the rarely reported association of the nephrotic syndrome and erythrocytosis, and the resolution of erythrocytosis with improvement of nephrotic syndrome.

Bone Marrow↗

PubMedDate not supplied

Verbal and visual memory improve after choline supplementation in long-term total parenteral nutrition: a pilot study.

BACKGROUND: Previous investigations have demonstrated that choline deficiency, manifested in low plasma-free choline concentration and hepatic injury, may develop in patients who require long-term total parenteral nutrition (TPN). Preliminary studies have suggested lecithin or choline supplementation might lead to improved visual memory in the elderly and reverse abnormal neuropsychological development in children. We sought to determine if choline-supplemented TPN would lead to improvement in neuropsychological test scores in a group of adult, choline-deficient outpatients receiving TPN. METHODS: Eleven subjects (8 males, 3 females) who received nightly TPN for more than 80% of their nutritional needs for at least 12 weeks before entry in the study were enrolled. Exclusion criteria included active drug abuse, mental retardation, cerebral vascular accident, head trauma, hemodialysis or peritoneal dialysis, (prothrombin time [PT] >2x control), or acquired immune deficiency syndrome (AIDS). Patients were randomly assigned to receive their usual TPN regimen (n = 6, aged 34.0 +/- 12.6 years) over a 12-hour nightly infusion or their usual TPN regimen plus choline chloride (2 g) (n = 5, aged 37.3 +/- 7.3 years). The following neuropsychological tests were administered at baseline and after 24 weeks of choline supplementation (or placebo): Weschler Adult Intelligence Scale-Revised (WAIS-R, intellectual functioning), Weschler Memory Scale-Revised (WMS-R, two subtests, verbal and visual memory), Rey-Osterrieth Complex Figure Test (visuospatial functioning and perceptual organization), Controlled Oral Word Association Test (verbal fluency), Grooved Pegboard (manual dexterity and motor speed), California Verbal Learning Test (CVLT, rote verbal learning ability), and Trail Making Parts A & B (visual scanning, psychomotor speed and set shifting). Scores were reported in terms of standard scores including z scores and percentile ranks. Mean absolute changes in raw scores were compared between groups using the Wilcoxon rank sum test, where p values < .05 constituted statistical significance. RESULTS: Significant improvements were found in the delayed visual recall of the WMS-R (7.0 +/- 2.7 vs -.33 +/- 5.7, p = .028), and borderline improvements in the List B subset of the CVLT (1.0 +/- 0.8 vs -2.0 +/- 2.4, p = .06) and the Trails A test (-3.8 +/- 8.1 vs 3.7 +/- 4.5 seconds, p = .067). No other statistically significant changes were seen. CONCLUSIONS: This pilot study indicates both verbal and visual memory may be impaired in patients who require long-term TPN and both may be improved with choline supplementation.

Adult↗

PubMedDate not supplied

Choline deficiency causes reversible hepatic abnormalities in patients receiving parenteral nutrition: proof of a human choline requirement: a placebo-controlled trial.

BACKGROUND: Previous studies have shown that plasma free choline concentrations are significantly decreased in many long-term home total parenteral nutrition (TPN) patients. Furthermore, low choline status has been associated with both hepatic morphologic and hepatic aminotransferase abnormalities. A preliminary pilot study suggested choline-supplemented TPN may be useful in reversal of these hepatic abnormalities. METHODS: Fifteen patients (10 M, 5 F) who had required TPN for > or =80% of their nutritional needs were randomized to receive their usual TPN (n = 8), or TPN to which 2 g choline chloride had been added (n = 7) for 24 weeks. Baseline demographic data were similar between groups. Patients had CT scans of the liver and spleen, and blood for plasma free and phospholipid-bound choline, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, gamma glutamyl transferase (GGT), bilirubin, serum lipids, complete blood count (CBC), and chemistry profile obtained at baseline, and weeks 2, 4, 6, 12, 16, 20, 24, and 34. CT scans were analyzed for Hounsfield unit (HU) densities. RESULTS: There were no significant differences in any measured parameters after 2 weeks. However, at 4 weeks, a significant difference in liver HU between groups was observed (13.3+/-5.0 HU [choline] vs 5.8+/-5.2 HU [placebo], p = .04). This significant trend continued through week 24. Recurrent hepatic steatosis and decreased HU were observed at week 34, 10 weeks after choline supplementation had been discontinued. A significant increase in the liver-spleen differential HU was also observed in the choline group (10.6+/-6.2 HU [choline] vs 1.3+/-3.3 HU [placebo], p = .01). Serum ALT decreased significantly (p = .01 to .05) in the choline group vs placebo at weeks 6,12, 20, and 24. Serum AST was significantly decreased in the choline group by week 24 (p = .02). The serum alkaline phosphatase was significantly reduced in the choline group at weeks 2, 12, 20, 24, and 34 (p = .02 to 0.07). Total bilirubin was normal in these patients and remained unchanged during the study. Serum GGT tended to decrease more in the choline group, but the greater decrease was not statistically significant. CONCLUSIONS: Choline deficiency is a significant contributor to the development of TPN-associated liver disease. The data suggest choline is a required nutrient for long-term home TPN patients.

Adult↗

PubMedDate not supplied

Plasma choline concentrations in children requiring long-term home parenteral nutrition: a case control study.

BACKGROUND: Low plasma free choline concentration has been associated with elevated serum hepatic aminotransferase concentrations and hepatic steatosis in adults who need home parenteral nutrition (HPN). We sought to determine if plasma free choline is similarly reduced in children who need home total parenteral nutrition (TPN). METHODS: We compared the plasma free choline concentration in 21 children who required long-term HPN with 31 normal controls. Patients had received HPN for 75 +/- 13 (SD) months (range 3-206 months). All control children ingested a normal, mixed, nonvegetarian diet. RESULTS: The mean plasma free choline concentration in the children receiving HPN was significantly lower than normal children (6.6 +/- 4.3 vs 8.0 +/- 2.3 nmol/mL, p = .002). Plasma free choline concentration was correlated with age (r = -0.43, p = .049). Using multiple linear regression analysis for age, sex, and squared age (considered in order to account for possible nonlinearity between choline and age), HPN children showed a steady and significant decline in plasma free choline concentration with increased age at the rate of 0.03 nmol/mL per month. Plasma lipid bound choline concentration did not vary with age. No relationship was seen between either plasma free and lipid bound choline concentration and amount of daily IV lipid infusion. A significant negative correlation was observed between plasma free choline concentration and aspartate aminotransferase (AST) and alanine aminostransferase (ALT) (r = -0.72, p = .04 and r = -0.80, p = .02, respectively). CONCLUSION: Our data support the notion that patients who need long-term HPN without significant enteral feeding have a significant risk for the development of choline deficiency with its associated hepatic dysfunction.

Adolescent↗

PubMedDate not supplied

Chemical analysis of soil and leachate from experimental wetland mesocosms lined with coal combustion products.

Small-scale (1 m2) wetland mesocosm experiments were conducted over two consecutive growing seasons to investigate the effects on soil and leachate chemistry of using a recycled coal combustion product as a liner. The coal combustion product used as a liner consisted of flue gas desulfurization (FGD) by-products and fly ash. This paper provides the chemical characteristics of mesocosm soil and leachate after 2 yr of experimentation. Arsenic, Ca, and pH were higher in FGD-lined mesocosm surface soil relative to unlined mesocosms. Aluminum was higher in the soils of unlined mesocosms relative to FGD-lined mesocosms. No significant difference of potentially phytotoxic B was observed between lined and unlined mesocosms in the soil. Higher pH, conductivity, and concentrations of Al, B, Ca, K, and S (SO4-S) were observed in leachate from lined mesocosms compared with unlined controls while Fe, Mg, and Mn were higher in leachate from unlined mesocosms. Concentrations of most elements analyzed in the leachate were below national primary and secondary drinking water standards after 2 yr of experimentation. Initially high pH and soluble salt concentrations measured in the leachate from the lined mesocosms may indicate the reason for early effects noted on the development of wetland vegetation in the mesocosms.

Coal↗

PubMedDate not supplied

A pilot study of intracavitary hyperthermia combined with radiation in the treatment of oesophageal carcinoma.

Twenty-five patients with primary squamous cell carcinoma of the oesophagus were treated with intracavitary hyperthermia combined with external beam radiation and intraluminal radiation at Nanjing Jinling Hospital, China. External beam radiation was given with a 6-MV X-ray; 1.8-2.0 Gy per fraction and five fractions per week; this brought the total dose to 60 Gy. Two weeks later, hyperthermia was applied with 915 MHz microwave intracavitary applicators, which were designed at the City of Hope. Temperature measurements were obtained while moving fibreoptic temperature sensors at 1.0 cm intervals in each of the six peripheral channels of the applicator. Hyperthermia was applied for 1 h before and after the intraluminal radiation. Intraluminal radiation was provided by low dose-rate iridium-192 ribbons in the same intracavitary applicator, giving 30 Gy at 0.75 cm from the applicator surface. The 3-month post-treatment responses showing complete response, partial response, no change and progressive disease were 60% (15/25), 24% (6/25), 8% (2/25) and 8% (2/25) respectively. The median follow-up time was 17 months (range 4-29 months). The 1- and 2-year overall survival rates were 72% (18/25) and 32% (8/25) respectively, and disease-free survival rates were 47 and 30% respectively. The median overall survival and disease-free survival periods were 17 and 10 months respectively. Fourteen patients had local recurrence (either at the primary site or in the lymph node) or had local progression, and five developed metastases. The median duration of the onset of local recurrence or of local progression was 9.5 months (range 0-20 months); the median of distant metastases was 8 months (range 2-16 months). Seventeen patients died. Of these, 15 died of cancer: six with local recurrence alone, four with local progression primary cancer alone, three with distant metastases alone, and two with both local and distant failure. Two patients with complete response of the primary disease died of other diseases. The toxicity was mild. According to the mucous reaction scoring criteria of the Radiation Therapy Oncology Group, the acute toxicity grades I, II, III and IV were 0% (0/25), 20% (5/25), 48% (12/25) and 32% (8/25) respectively. The major late complication was a mild oesophagus fibrosis and difficult swallowing. No serious side effects (grade IV), fistulas or perforations were seen. These results indicate that this method is safe and feasible for treating oesophageal carcinoma.

Combined Modality Therapy↗

PubMedDate not supplied

Transtubular potassium concentration gradient (TTKG) and urine ammonium in differential diagnosis of hypokalemia.

BACKGROUND: Hypokalemia is a common and sometimes serious clinical problem, whose etiological diagnosis can frequently be based on the patient's history and the clinical setting. Measurement of urinary indices such as excretory rate of K+, random urine K+ concentrations and blood acid-base parameters have been employed in the pathophysiological diagnosis, though with some pitfalls. METHODS: To investigate the diagnostic usefulness of the transtubular potassium concentration gradient (TTKG) and urine ammonium in the differentiation of hypokalemia, we measured serum K+ and osmolality, random urine electrolytes, osmolality and ammonium, the urinary [Na]/[K] ratio (U(Na)/K), plasma aldosterone and TTKG in 7 patients with diarrhea, 6 with vomiting, 7 with mineralocorticoid excess, 6 with diuretic usage, and compared them with those of 7 overnight fasted and acid-loaded healthy volunteers. RESULTS: The urine K+ concentrations did not reflect urinary loss of potassium according to the subjects' hydration status. U(Na)/k in the hypokalemic patients with mineralocorticoid excess (1.4 +/- 0.5) was lower than in normal subjects (2.3 +/- 0.4) (p<0.05). TTKG was higher in hypokalemic patients with mineralocorticoid excess (13.3 +/- 4.4) and diuretic usage (8.6 +/- 1.3) and lower in those with diarrhea (1.6 +/- 0.3) than in the normal controls (5.0 +/- 0.7) (p<0.5). TTKG in the patients with vomiting (3.5 +/- 0.6) was the same as in normal controls. TTKG was stronger correlated with the plasma aldosterone levels in the hypokalemic patients due to renal potassium loss. Urine ammonium concentrations of the acid-loaded normal subjects (73.3 +/- 5.0 mEq/L), patients with diarrhea (74.4 +/- 2.0 mEq/L) and patients with mineralocorticoid excess (68.7 +/- 6.9 mEq/L) were higher than in overnight-fasted normal subjects (31.3 +/- 4.9 mEq/L). CONCLUSION: TTKG and random urine ammonium were useful in the pathophysiological differential diagnosis of hypokalemia.

Diagnosis, Differential↗

PubMedDate not supplied

Bilateral emphysematous pyelonephritis with perirenal abscess cured by conservative therapy.

Emphysematous pyelonephritis is a rare life-threatening infection of the renal parenchyma. It usually affects unilateral kidney and occurs mostly in diabetic patients. It is characterized by the presence of gas within the renal parenchyma and requires prompt diagnosis and early aggressive therapy. Bilateral emphysematous pyelonephritis is even more rare and is associated with high mortality. We describe a case of a 62-year-old diabetic woman who presented with nonketotic hyperosmolar coma and bilateral emphysematous pyelonephritis caused by Klebsiella pneumoniae. Diagnosis of bilateral emphysematous pyelonephritis was confirmed by an abdominal computed tomographic scan and microbiologic studies. Our patient was successfully treated using percutaneous catheter drainage and long-term antibiotic therapy.

Abdominal Abscess↗