Cyclical Vomiting Syndrome: Psychiatrist's View Point.

Cyclical vomiting syndrome (CVS) is an idiopathic functional disorder characterized by recurrent episodes of nausea and vomiting separated by symptom-free intervals. Even though initially described in children, it is seen in all age groups. Exact etiology is not known. Various physical, infectious, and psychosocial stressors have been implicated for CVS. High incidence of psychiatric comorbidities such as panic attacks, anxiety disorder, and depression is seen in CVS. Most children outgrow CVS with time though some may transition to migraine or continue to have CVS as adults. Frequent misdiagnosis, delay in diagnosis, or inadequate treatment often lead to years of recurrent vomiting. This case report highlights the importance of the management of CVS by a multidisciplinary team including a psychiatrist in addressing the various physical and psychological factors effectively and that would result in faster and prolonged recovery.

Joubert syndrome with autism in two siblings: A rare presentation.

Joubert syndrome is a rare autosomal recessive disorder with partial or complete agenesis of cerebellar vermis. This syndrome is identified mainly by the presence of molar tooth sign in magnetic resonance imaging of the brain since it has a varied phenotypic presentation. Of the 200 cases reported so far in the literature, only three reports show the presence of autistic symptoms in siblings suggesting a link between the cerebellar vermis and autistic spectrum disorders. In this case report of two siblings, the female child satisfied the criterion for autistic spectrum disorder in accordance with Diagnostic and Statistical Manual of Mental Disorders Fifth Editon. The boy showed developmental delay with autistic features (not amounting to diagnostic threshold). This report is important in that it adds evidence to the literature that abnormalities of cerebellum are involved in the cognitive development and autistic symptoms.

Weekly cisplatin (30-40 mg/m2) as radiosensitizer: Is it high or moderate emetic agent?

PURPOSE: The American Society of Clinical Oncology (ASCO) guideline recommends a high antiemetic prophylaxis for any dose of cisplatin. This hypothesis was tested by us in this analysis of solid tumor patients who received weekly cisplatin as a radiosensitizer in a dose range of 30-40 mg/m2. METHODS: This was a retrospective analysis of 181 solid tumor patients who received weekly cisplatin (in the dose range of 30-40 mg/m2) as a radiosensitizer between July 2015 and August 2015. The antiemetic prophylaxis schedule provided was classified as optimal (if a high antiemetic prophylaxis was provided) or suboptimal (if a nonhigh antiemetic prophylaxis was provided). The incidence of acute, delayed and breakthrough vomiting after chemotherapy was noted. SPSS version 20 was used for analysis. Fisher's exact test was used to determine the association between antiemetic schedule (suboptimal vs. optimal) and postchemotherapy emesis. RESULTS: In the present study, of 181 patients, only 25 patients (13.8%) received optimal antiemetic prophylaxis while the remaining 156 (86.2%) received suboptimal prophylaxis. In the cohort of patients with suboptimal prophylaxis, dexamethasone was omitted in all patients (100%) while NK receptor antagonist was omitted in 76 patients (48.7%). The rate of vomiting was lower in patients receiving optimal prophylaxis as compared to that in patients receiving suboptimal prophylaxis (12% vs. 39.75%; P - 0.005). CONCLUSION: Omission of dexamethasone followed by aprepitant was the main reason for suboptimal prophylaxis. High antiemetic prophylaxis in accordance with ASCO guidelines overall decreased the risk of emesis in patients receiving CTRT with weekly cisplatin in the dose range of 30-40 mg/m2.

The story of a girl with weeping blood: Childhood depression with a rare presentation.

Ms. V, a 10-year-old girl was referred to Child Psychiatry Department with complaints of bleeding from eyes for last 3 months. Bleeding was spontaneous, recurrent, painless, and self-limited. History revealed significant Psychological stressors, Temperamental Difficulties and Conflicts with Mother. Mental status examination revealed Depression in Ms. V. During hospital stay, Ms. V developed repeated bleeding episodes. The presence of hemoglobin is confirmed in the bleeding sample. Hematologic investigations and computed tomography brain were normal. Ms. V was started on Sertraline, Propranolol, and Clonazepam. Both Ms. V and her Mother were psycho-educated about the nature of the illness. Ms. V was discharged and under follow-up. This case is reported for the rarity of presentation (bleeding from Eyes) of a childhood Depression.

Factors causing delay in discharge of elderly patients in an acute care hospital.

INTRODUCTION: Prolonged hospitalisation not only increases cost, it is also associated with other complications. Length of stay (LOS) is one of the indicators that reflect total cost of care during hospitalisation. So, it is of paramount importance to find out why elderly patients overstay in acute care hospitals and address these issues proactively. Since no local data is available, a study was planned to ascertain reasons why the discharging of elderly patients from hospital is delayed and whether these reasons are avoidable. MATERIALS AND METHODS: Long-stay patients were defined as those whose LOS had notably exceeded the average LOS for the Diagnosis Related Group (DRG), based on principal admitting diagnosis. A separate analysis showed that the specialty-specific long-stay marker for geriatric medicine was 28 days, so casenote review was done for all patients with LOS of more than 28 days who were discharged from geriatric medicine service of an acute care hospital during a 1-year study period. Information was collected on demographic profile, functional and cognitive status, past medical and social history, admitting medical diagnoses, discharge limiting and delaying factors. RESULTS: During the study period, 150 patients stayed over 28 days and 137 casenotes were available for review. The mean age of the patients was 84 years, 55.5% were female, 77.4% were Chinese, mean abbreviated mental test (AMT) score was 3 and mean modified Barthel's score was 11. The commonest primary diagnosis was sepsis followed by neurological problems, falls-related complication and cardiovascular diseases. The 2 most common discharge limiting factors (the final event which resulted in delay in discharge) were social issues (54, 39.4%) and sepsis (47, 34.3%). Of 47 patients with sepsis, 37 (78.7%) were nosocomial infection. Urinary tract infection and pneumonia were the 2 most common nosocomial infections. The 4 most common factors contributing to delayed discharge (various problems that surfaced throughout the hospital stay) were sepsis (94, 68.6%), deconditioning (65, 47.4%), social issues (52, 38.0%) and cardiovascular disorders (37, 27.0%). CONCLUSION: Elderly patients are more prone to hospitalisation-related complications like nosocomial infection and deconditioning leading to prolonged hospital stay. Early interventions can reduce these complications. Early identification of social issues and prompt discharge planning should be done to avoid delay in discharge.

Complications in stroke patients: a study carried out at the Rehabilitation Medicine Service, Changi General Hospital.

AIM: The aim of this study was to look at the type and frequencies of complications after an acute stroke in an inpatient rehabilitation setting. We also looked at the type of complications which required the transfer of patient care back to the primary referring physician. MATERIALS AND METHODS: A retrospective review of case notes of patients transferred to the rehabilitation team was conducted. The study period was a six-month period from the beginning of January 2001 to the end of June 2001. A list of complications was made. Each pre-determined complication was then defined. The frequency of each complication was then calculated. RESULTS: A total of 140 case notes were reviewed. The overall complication rate was 54.3%. The more common complications, in order, from highest to lowest frequencies, were: constipation (complicating 22.9% of strokes); acute retention of urine (ARU, 20.9%); urinary tract infections (UTI, 14.3%); depression (9.3%); and limb pain (8.6%). Females were more likely to have UTI (p=0.038), ARU (p=0.002) and depression (p=0.018). Patients 65 years and above were more likely to suffer multiple complications although the results did not reach statistical significance (p=0.055). The care for eight patients (5.7% of patients with complications) had to be transferred back to the primary referring team or physician. CONCLUSIONS: Complications post stroke are common. Some patients required transfer of care back to the primary referring physician. A pro-active approach is ideal in all post stroke patients, in order to identify and treat any complications early, thereby, improving outcome and reducing costs.

Evaluation of antimicrobial and lipopolysaccharide-neutralizing effects of a synthetic CAP18 fragment against Pseudomonas aeruginosa in a mouse model.

CAP18 (cationic antimicrobial protein; 18 kDa) is a neutrophil-derived protein that can bind to and inhibit various activities of lipopolysaccharide (LPS). The 37 C-terminal amino acids of CAP18 make up the LPS-binding domain. A truncated 32-amino-acid C-terminal fragment of CAP18 had potent activity against Pseudomonas aeruginosa in vitro. We studied the antimicrobial and LPS-neutralizing effects of this synthetic truncated CAP18 peptide (CAP18106-137) on lung injury in mice infected with cytotoxic P. aeruginosa. To determine its maximal effect, the CAP18106-137 peptide was mixed with bacteria just prior to tracheal instillation, and lung injury was evaluated by determining the amount of leakage of an alveolar protein tracer (125I-albumin) into the circulation and by the quantification of lung edema. The lung injury caused by the instillation of 5 x 10(5) CFU of P. aeruginosa was significantly reduced by the concomitant instillation of CAP18106-137. However, the administration of CAP18106-137 alone, without bacteria, induced lung edema, suggesting that it has some toxicity. Also, the peptide did not significantly reduce the number of bacteria that had been simultaneously instilled, nor did it significantly improve the survival of the infected mice. The addition of CAP18106-137 to aztreonam along with the bacteria did decrease the level of antibiotic-induced release of inflammatory mediators including tumor necrosis factor alpha, interleukin-6, and nitric oxide and also improved the survival of the mice. Therefore, more investigations are needed to confirm the toxicities and the therapeutic benefits of CAP18106-137 as an adjunctive therapy to antibiotics in the treatment of infections caused by gram-negative bacteria.

Induction of cyclooxygenase-2 in alveolar macrophages after acid aspiration: selective cyclooxygenase-2 blockade reduces interleukin-6 production.

BACKGROUND: Gastric acid aspiration can result in acute lung injury. In this study, the authors determined whether alveolar macrophages express cyclooxygenase-2 as a source of inflammatory mediators after acid aspiration. METHODS: Seventy-five microliters of hydrochloric acid solution, pH 1.15, was instilled into one lung in mice. After exposure, alveolar macrophages were harvested, and competitive polymerase chain reaction and enzyme-linked immunosorbent assay were performed to measure expression of cyclooxygenase-1 and -2, interleukin-1beta and -6, tumor necrosis factor-alpha, and inducible nitric oxide synthase (iNOS). The authors used immunocytochemistry to demonstrate expression of cyclooxygenase-2 in alveolar macrophages. Selective cyclooxygenase-2 blockade using N-2(-cyclohexyloxy-4-nitrophenyl) methane-sulphonamide was done to characterize prostaglandin-cytokine interaction. RESULTS: Acid aspiration induced upregulation of cyclooxygenase-2 and interleukin-6. Tumor necrosis factor-alpha and iNOS were not upregulated. Interleukin-1beta was upregulated even with saline instillation but could not be detected in the supernatant of the cell culture. Alveolar macrophages harvested from mice instilled with acid showed a trend toward more production of prostaglandin E2 and produced higher concentrations of interleukin-6 compared with alveolar macrophages from mice instilled with saline. Selective cyclooxygenase-2 blockade significantly decreased release of interleukin-6 from alveolar macrophages harvested from mice instilled with acid. CONCLUSIONS: Acid aspiration induces strong expression of cyclooxygenase-2 and production of interleukin-6 in alveolar macrophages. Selective cyclooxygenase-2 blockade reduced production of interleukin-6 by acid-stimulated alveolar macrophages. These studies suggest that the induction of cyclooxygenase-2 plays an important role in the systemic inflammatory response induced by acid aspiration.

The broad-range phospholipase C and a metalloprotease mediate listeriolysin O-independent escape of Listeria monocytogenes from a primary vacuole in human epithelial cells.

Intracellular growth of Listeria monocytogenes begins after lysis of the primary vacuole formed upon bacterial entry into a host cell. Listeriolysin O (LLO), a pore-forming hemolysin encoded by hly, is essential for vacuolar lysis in most cell types. However, in human epithelial cells, LLO- mutants are capable of growth, suggesting that gene products other than LLO are capable of mediating escape from a vacuole. In this study, we investigated the role of other bacterial gene products in lysis of the primary vacuole in the human epithelial cell line Henle 407. Double internal in-frame deletion mutants were constructed by introducing a mutated hly allele into strains harboring deletions in either of the phospholipase C (PLC)-encoding genes or a metalloprotease-encoding gene. Bacterial escape from the primary vacuole, intracellular growth, and cell-to-cell spread were evaluated in Henle 407 cells. The results indicated that, in the absence of LLO, the broad-range PLC and the metalloprotease were both required for lysis of the primary vacuole in Henle 407 cells. Although phosphatidylinositol-specific PLC was not required, the efficiency of escape was reduced in an LLO phosphatidylinositol-specific PLC double mutant. These observations suggest that the relative importance of LLO, the phospholipases, and the metalloprotease may vary in different cell types or in cells from different species. In addition, these studies provide insight into the mechanisms of action of virulence determinants involved in the lysis of vacuolar membranes.

Sequential health effect study in relation to air pollution in Bombay, India.

A health study done for 4 years in 4129 subjects from 3 urban (high, medium and low according to SO2 levels) and a rural community showed a higher morbidity with raised levels. Initially in the respective 4 areas standardised prevalences (in percent) were: for dyspnoea 7.3, 6, 3.2 and 5.5; for chronic cough 5.1, 2.7, 1.7 and 3.3; for intermittent cough 15.6, 5.8, 0.4 and 3.7 and frequent colds 18.0, 20.8, 12.1 and 11 percent. The diagnosis of chronic bronchitis was done in 4.5, 4.5, 2.3 and 5.0 percent and cardiac disorders 6.8, 4.3, 8.2 and 2.7 percent in respective 4 areas. After 3 years, 55-60% of urban and 44% of rural subjects were reassessed. Several minor symptoms, besides above ones were related closely to the urban air pollutant profile. Increased greenery protected only at lower levels of pollution. Initial lung functions were best in "urban low" area but in all urban areas, yearly declines were larger than in rural subjects. A cross sectional study for effect of slums in 4 areas on 22272 subjects revealed generally higher morbidity in slum residents, particularly in "urban medium" area for frequent colds, cough and dyspnoea. Daily health diaries maintained in 2232 subjects revealed high morbidity in 2 more polluted areas; monthly trends correlated to SO2 and S.P.M. and daily fluctuations with SO2 revealed a threshold between 50 to 100 micrograms/CM/day. There were greater mortality (S.M.R.) in cardiorespiratory and malignant diseases related to pollution. The major factors affecting morbidity were pollution, nutrition, occupation, smoking and age.

Gas chromatographic determination of histapyrrodine hydrochloride in pharmaceutical preparations.

A simple gas chromatographic method is described for the determination of histapyrrodine HCl in marketed formulations. Chlorpheniramine maleate is used as the internal standard. The amount of histapyrrodine HCl found by the proposed method averaged 19.91 mg/tablet, compared with the label claim of 20 mg/tablet. The method was statistically evaluated for accuracy and precision.

Simple colorimetric method for determination of thiamine hydrochloride in pharmaceuticals.

A simple colorimetric method is described for the determination of thiamine hydrochloride (vitamin B1) in dosage forms. The method is based on measurement of a yellow complex formed when thiamine HCl is treated with p-methylaminophenol sulfate (Metol) under alkaline conditions. Compounds such as vitamins A, B2, B6, B12, C, D, and E, and niacinamide, citric acid, liquid glucose, calcium pantothenate, biotin, liver extract, and folic acid do not interfere in the reaction. Extracting the complex into chloroform before quantitation enhances the stability of the reaction product and removes interference of water-soluble colored constituents in syrup samples. Statistical validation shows that the method is precise and accurate. Results agree well with those obtained by other methods in the literature.

Simple colorimetric method for determination of metaproterenol sulfate in pharmaceuticals.

A simple colorimetric method is described for the determination of metaproterenol sulfate (orciprenaline sulfate). The method is based on measurement of a colored species formed when metaproterenol sulfate is treated with diazotized dapsone, p-nitroaniline, or benzocaine at room temperature, followed by treatment with an aqueous solution of trimethylamine in the case of benzocaine. Compounds such as starch, talc, and common excipients do not interfere in the reaction. Statistical validation showed that the method was precise and accurate. The results agree well with those obtained by other methods reported in the literature.

Disseminated Strongyloides stercoralis: a fatal case eluding diagnosis.

We have described a patient who died of disseminated strongyloidiasis as a result of steroid therapy, despite an extensive diagnostic evaluation in the face of eosinophilia, but before any immunosuppressive therapy. This death might have been prevented by presumptive treatment after work-up but before immunosuppressive therapy, and repeat diagnostic evaluation after antistrongyloides therapy and during immunosuppressive therapy.