Antidepressant-induced tardive syndrome: a retrospective epidemiological study.

INTRODUCTION: The impact of using antidepressant on the occurrence of tardive syndrome is rarely studied. Here we aimed to investigate the prevalence of various types of antidepressant induced tardive syndrome. METHODS: This study was conducted by means of a retrospective survey. Subjects receiving antidepressant(s) for over 6 months, but no other agents that may cause involuntary movements, were consecutively recruited. Tardive syndrome was evaluated in every included subject. Possible confounding medical conditions were carefully ruled out. RESULTS: Of the 158 included subjects, 22 (14.0 %) were found to have at least one tardive syndrome. The prevalence of subtypes of tardive syndromes was: tardive dystonia: 10.8 %, tardive dykinesia: 3.2 %, tardive tremor: 1.3 %, tardive parkinsonism: 1.3 %, tardive tics: 1.3 %, tardive sensory syndrome: 1.3 %, and tardive myoclonus: 0.6 %. Using serotonin-norepinephrine reuptake inhibitors and previous marital status significantly increase the risk of tardive syndrome. DISCUSSION: This study showed that antidepressants may induce various types of tardive syndrome, of which tardive dystonia is the predominant form. Clinicians should be cautious of this infrequent but distressing adverse effect when using antidepressants.

Genome-wide association study of bipolar I disorder in the Han Chinese population.

We report the first genome-wide association study in 1000 bipolar I patients and 1000 controls, with a replication of the top hits in another 409 cases and 1000 controls in the Han Chinese population. Four regions with most strongly associated single-nucleotide polymorphisms (SNPs) were detected, of which three were not found in previous GWA studies in the Caucasian populations. Among them, SNPs close to specificity protein 8 (SP8) and ST8 α-N-acetyl- neuraminide α-2,8-sialyltransferase (ST8SIA2) are associated with Bipolar I, with P-values of 4.87 × 10(-7) (rs2709736) and 6.05 × 10(-6) (rs8040009), respectively. We have also identified SNPs in potassium channel tetramerization domain containing 12 gene (KCTD12) (rs2073831, P=9.74 × 10(-6)) and in CACNB2 (Calcium channel, voltage-dependent, ß-2 subunit) gene (rs11013860, P=5.15 × 10(-5)), One SNP nearby the rs1938526 SNP of ANK3 gene and another SNP nearby the SNP rs11720452 in chromosome 3 reported in previous GWA studies also showed suggestive association in this study (P=6.55 × 10(-5) and P=1.48 × 10(-5), respectively). This may suggest that there are common and population-specific susceptibility genes for bipolar I disorder.

A cross-ethnic comparison on incidence of suicide.

BACKGROUND: Suicide rates vary widely across nations and ethnic groups. This study aims to explore potential factors contributing to inter-ethnic differences in suicide rates. METHOD: Study subjects came from a case-control psychological autopsy study conducted in Taiwan, including 116 consecutive suicides from two aboriginal groups and Taiwanese Han; 113 of them each matched with two living controls. Gender-, age- and method-specific suicide rates, population attributable fraction (PAF) of suicide for five major risk factors, help-seeking before suicide and emergency medical aid after suicide were compared between the three ethnic groups. RESULTS: One aboriginal group (the Atayal) had significantly higher adjusted rate ratios (RR) of suicide than the other aboriginal group (the Ami) [RR 0.20, 95% confidence intervals (CI) 0.12-0.34] and the Han (RR 0.26, 95% CI 0.16-0.40). Such differences can be explained by higher PAFs of suicide for three major risk factors (substance dependence, PAF 47.6%, 95% CI 25.5-64.2; emotionally unstable personality disorder, PAF 52.7%, 95% CI 32.8-69.0; family history of suicidal behaviour, PAF 43.5%, 95% CI 23.2-60.2) in this group than in the other two groups. This higher suicide rate was substantially reduced from 68.2/100 000 per year to 9.1/100 000 per year, comparable with the other two groups, after stepwise removal of the effects of these three risk factors. Suicide rates by self-poisoning were also significantly higher in this group than in the other two groups. CONCLUSIONS: Higher rates of specific risk factors and use of highly lethal pesticides for suicide contributed to the higher suicide rate in one ethnic group in Taiwan. These findings have implications for developing ethnicity-relevant suicide prevention strategies.

Ovine model as a surgical simulator for pediatric laryngotracheal reconstruction.

OBJECTIVES: There are increasing pressures on the health system and training programs to provide adequate training opportunities for surgical trainees. This is particularly true with respect to complex procedures that are performed less commonly. We sought to develop an ovine model for the simulation of pediatric laryngotracheal reconstruction (LTR) and validate its use for training. METHODS: Knee-high lamb specimens were sourced from an accredited Australian abattoir that included structures of the neck, cervical spine and subcutaneous tissues from the thyroid cartilage to the carina. Specimens were positioned and draped to simulate surgical exposure. Otorhinolaryngology residents and consultants performed two LTRs on separate specimens that were video recorded for assessment of performance. RESULTS: Sixteen LTRs were performed by eight participants. Performance of experienced (advanced) participants was significantly better than novice participants (p = 0.001). There was a strong linear association between general surgical competence and procedural performance (r = 0.88). The developed assessment scales demonstrated strong reliability and internal consistency (Cronbach's α = 0.83). CONCLUSIONS: The complexity of pediatric airway surgery makes simulation an attractive option for developing skills that are transferrable to the operating setting. The ovine model presented here has similarities in size, structure and tissue characteristics to the pediatric airway that make it an ideal model for simulating pediatric LTR. It is a low-cost, readily available option for otorhinolaryngology residents to develop and refine essential skills throughout their training.

Use of non-invasive ventilation in children with congenital tracheal stenosis.

INTRODUCTION: Congenital tracheal stenosis (CTS) is a rare airway condition characterized by complete tracheal rings. Most patients undergo a slide tracheoplasty, which greatly reduces mortality but significant morbidity remains. The assessment of sleep disordered breathing (SDB) and use of non-invasive ventilation (NIV) in these children has not been described. AIM: To describe the presence of SDB and use of NIV in children diagnosed with CTS over a 10-year period (2005-2015). DESIGN: Retrospective case series at a tertiary children's hospital. RESULTS: There were 16 patients identified with CTS with a median [range] age at diagnosis of 2.5 months (0-9 months). One child died in the immediate post-operative period following a slide tracheoplasty, leaving 15 survivors. There were no later deaths during follow-up while using NIV for up to 3 years after surgery. Slide tracheoplasty was undertaken in (12/15) with long-segment tracheal stenosis. 3/15 patients had a short-segment tracheal stenosis and were managed conservatively. The use of NIV occurred in 10/15 (66.67%) patients, all of whom had long-segment CTS. Pre-operative polysomnography (PSG) showed a median (±SD) obstructive apnoea/hypopnoea index (OAHI) of 14.6/hr (±6.2) which reduced to 7.2/hour (±4.2) on NIV prior to slide tracheoplasty. The median oxygen desaturation index (ODI) before NIV use was 15.3 (±19.4) episodes/hour, which reduced to 6.3 (±11) on NIV. The median period of NIV use was 5 [1-24 months] months. CONCLUSION: Patients with CTS have obstructed sleep disordered breathing. Trials of NIV are well-tolerated and improve sleep disordered breathing.

Acquired tracheal diverticulum following repair of tracheo-oesophageal fistula: endoscopic management.

Remnant tracheal diverticulum following the repair of a tracheo-oesophageal fistula (TOF) is an uncommon complication. The majority of lesions are discovered and repaired at the time of primary oesophageal repair. Respiratory complications are reported to be a major cause for morbidity after surgical repair of a TOF. They include anastomotic stricture, oesophageal dysmotility and tracheomalacia. These case reports highlight the need to be wary of tracheal diverticulum as a complication following the repair of a TOF, which may cause difficulty in intubation, airway compromise or an inability to provide effective ventilation. An effective endoscopic surgical technique has been described.

Prognostic effect of pre- and post-admission antibiotic treatment in paediatric acute mastoiditis.

OBJECTIVE: To evaluate the effect of pre- and post-admission antibiotic treatment in paediatric acute mastoiditis. DESIGN: Retrospective study. METHOD: Eighty-eight children with acute mastoiditis, from 2003 to 2012, were studied to investigate the effect of antibiotic therapy on short and long-term sequelae. RESULTS: The median period of antibiotic therapy immediately following hospital discharge was 10 days (range, 5-49 days; standard deviation = 7.46). There were no sequelae within the fortnight following antibiotic therapy completion, but 14 of 40 patients had significant sequelae thereafter, including recurrent otorrhoea, acute otitis media and ventilation tube insertion requirement. Complication rates were significantly higher among patients who had pre-admission antibiotic therapy (52 per cent), compared to patients previously untreated (27 per cent). CONCLUSION: Paediatric acute mastoiditis patients treated with antibiotic therapy prior to admission are at higher risk for complication development. The advised time period for oral antibiotic therapy following hospital discharge remains as 10 days in all cases of uncomplicated acute mastoiditis.

Wide anterior neck dissection for management of recurrent thyroglossal duct cysts in adults.

OBJECTIVE: Thyroglossal duct cyst recurrence following resection is attributed to anatomical variability and residual thyroglossal ducts. In adults, thyroglossal duct cyst recurrence is extremely rare and a surgical solution is yet to be well explored. This paper describes our approach to the management of recurrent thyroglossal duct cysts and sinuses in adults using a wide anterior neck dissection. METHOD: A retrospective review was performed to identify adults who underwent a wide anterior neck dissection for recurrent thyroglossal duct cyst management between 1 January 2009 and 1 January 2015. RESULTS: Six males and one female were included in the series (mean age, 26.4 ± 10.9 years). Recurrence occurred at a mean of 18 ± 9.8 months following primary surgical management (3 patients underwent cystectomy and 4 had a Sistrunk procedure). All patients subsequently underwent wide anterior neck dissection; there was no further recurrence over the 12-month average follow-up period. CONCLUSION: This paper describes a wide anterior neck dissection technique for the management of recurrent thyroglossal duct cysts or sinuses in adults; this approach addresses the variable anatomy of the thyroglossal duct and is associated with minimal morbidity.

Mental illness and suicide. A case-control study in east Taiwan.

BACKGROUND: As part of the Taiwan Aboriginal Study Project, a case-control study of suicide among two aboriginal groups and the Han Chinese was carried out in East Taiwan. METHODS: Biographical reconstructive interviews were conducted for consecutive suicides from each of the three ethnic groups (a total of 116 suicides), 113 of whom were matched with two controls for age, sex, and area of residence. RESULTS: In all three groups, a high proportion of suicides suffered from mental illness before committing suicide (97% to 100%). The two most prevalent psychiatric disorders were depression and alcoholism, and the most common comorbid pattern was depression with substance use disorders. The risk for suicide was significantly associated with all of these psychiatric conditions, previous suicide attempts, and a family history of suicide and depression. Fifty-one percent of all suicides had consulted medical professionals in the previous month. CONCLUSION: Despite the widely different rates of depressive illness and alcoholism in different cultures previously reported, the psychiatric antecedents of suicide are the same in the West and the East.

Alcohol dehydrogenase and aldehyde dehydrogenase genotypes and alcoholism among Taiwanese aborigines.

Previous population association studies have indicated that certain alleles of alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) genes may reduce the risk of alcoholism in Oriental populations. In this report we determined the genotypes for three genes, ADH2, ADH3, and ALDH2 among subjects with alcohol dependence (n = 159) and ethnically matched normal controls (n = 149) for the four largest aboriginal groups (Atayal, Ami, Bunun, and Paiwan) in Taiwan. The ethnicity matching used in this study was feasible because there are still few intergroup marriages between these aboriginal groups. On a group level, the rare frequencies of ALDH2*2, the inactive allele of ALDH2, among these aborigines may account partially for their vulnerability to alcohol use disorders. On an individual level, however, the genotypes controlling alcohol metabolism did not account for intragroup differences in vulnerability to alcoholism except in the case of ADH2 for the Ami ethnic group.

Association of monoamine oxidase A alleles with alcoholism among male Chinese in Taiwan.

OBJECTIVE: The role of monoamine oxidase (MAO) in alcoholism was assessed by genetic association studies separately in five ethnic groups in Taiwan. METHOD: Restriction fragment length polymorphisms (RFLP) and dinucleotide repeat polymorphisms (DNRP) were used to determine MAOA and MAOB alleles in male alcoholic patients and nonalcoholic comparison subjects among Han Chinese and four aboriginal groups. RESULTS: Significant associations of alcohol dependence with MAOA alleles (RFLP and DNRP) were found among the Han Chinese, but not among the aboriginal groups. No significant association with MAOB DNRP alleles was found in any group. CONCLUSIONS: Genetic heterogeneity may underlie alcoholism among different ethnic groups in Taiwan, and MAOA mutations may play a role in susceptibility to alcoholism among Han Chinese.

Community-based molecular epidemiology of HTLV type I in Taiwan and Kinmen: implication of the origin of the cosmopolitan subtype in northeast Asia.

To understand the possible origin and dissemination of HTLV-I infection in northeast Asia, community-based molecular epidemiological studies were conducted on the Kinmen Islands (off the coast of Fukien Province, China) and in Taiwan. A total of 3831 Taiwanese from 3 townships (Pu-Li, Chu-Dung, and Pu-Tze) and 993 aborigines from 4 tribes in Taiwan participated in this study. The prevalence rates of HTLV-I infection in adult residents from Pu-Li, Chu-Dung, and Pu-Tze were 0.82, 1.72, and 1.63%, respectively. None of the aborigines had HTLV-I infection. Previously, 0.73% of the adult population of Kin-Hu, Kinmen were found to have HTLV-I infection. Peripheral blood mononuclear cells were collected from HTLV-I carriers identified both in Taiwan and Kinmen and the HTLV-I LTR sequences were PCR amplified, subcloned, and sequenced for phylogenetic tree analysis. The results showed that all 6 HTLV-I isolates from Kinmen and 13 of 18 (72.2%) isolates from Taiwan were group a (transcontinental) of Cosmopolitan subtype, while 5 of 18 (27.8%) isolates from Taiwan were group b (Japanese) of Cosmopolitan subtype. Since all of the HTLV-I-infected persons were descendants of immigrants from mainland China, the origin of the Cosmopolitan subtype in Taiwan and Kinmen may not have been Japan, as previously theorized, but China, possibly the result of the migration of an infected population in the past several centuries.

Dopamine D2 receptor gene and alcoholism among four aboriginal groups and Han in Taiwan.

Previous studies examining the putative association between DRD2 TaqI A1 and alcoholism have produced conflicting results. Major critiques of such studies include potential confounding arising from population admixture by inappropriate selection of controls, failure to screen out substance abusers from controls, and the failure to assess the severity of alcoholics. To address these issues, we compared the allelic frequency of two polymorphisms of DRD2, TaqI A and NcoI, among severe alcoholics and their ethnically matched nonalcoholic controls within four major aboriginal groups and Han (Chinese) in Taiwan. The sample of alcoholics and controls examined for the five groups included 36 and 31 (Atayal), 24 and 23 (Ami), 58 and 58 (Bunun), 35 and 35 (Paiwan), and 50 and 66 (Han). A borderline association between TaqI A1 and alcoholism among the Ami (P = 0.08) and an association between NcoI N1 and alcoholism among Han (P = 0.01) were found. Results of haplotype analysis further confirm that the frequency of haplotype A1N1 was higher in alcoholics than in controls for the Ami (P = 0.01) and Han (P = 0.03). If controls with tobacco abuse were excluded from the analysis, the results remained unchanged. Severity in medical complications of alcohol dependence with withdrawal symptoms was not associated with higher prevalence of DRD2 TaqI A1 or NcoI N1 alleles. The absence of an association between DRD2 and alcoholism among the three aboriginal groups suggests either a higher rate of phenocopies among aboriginal alcoholics or genetic heterogeneity in the susceptibility to alcoholism.

Search for mutations near the alternatively spliced 8-amino-acid exon in the GABAA receptor gamma 2 subunit gene and lack of allelic association with alcoholism among four aboriginal groups and Han Chinese in Taiwan.

The alternatively spliced 8-amino-acid exon for the GABAA receptor gamma2 subunit gene (GABRC2) has been postulated to mediate behavioral actions of alcohol. A rapid search for splice-junction mutations near the 8-amino-acid exon using restriction enzymes which normally recognize sequences near or in the exon gave negative results among 217 alcoholics in four aboriginal groups (Ami, Atayal, Bunun and Paiwan) and Han Chinese in Taiwan. The role of the GABRC2 gene in alcoholism was further assessed by a comparison of allelic frequencies revealed by a NciI RFLP between case and control groups. No significant association of alcohol dependence with GABRC2 alleles was observed. These results suggest that the GABRC2 gene probably does not play an essential role in predisposition to alcoholism in the sample population.

Genetic polymorphisms of the promoter region of dopamine D2 receptor and dopamine transporter genes and alcoholism among four aboriginal groups and Han Chinese in Taiwan.

This study aims to examine the relationship between the functional polymorphism at the promoter region of the dopamine D2 receptor (DRD2) gene (i.e. -141C Ins/Del) and variable number of tandem repeat polymorphism at the 3' untranslated region of the dopamine transporter (DAT) gene (SLC6A3) with alcoholism in a case-control study. The cases (n = 203) were alcohol dependents with withdrawal symptoms, and the controls (n = 213) were sex- and ethnicity-matched individuals who were screened to exclude those with alcohol problems among four aboriginal groups (Atayal, Ami, Bunun, and Paiwan) and Han Chinese in Taiwan. To control for potential confounding factors, we excluded tobacco abusers from control subjects in part of the analysis and compared the distribution of the genetic polymorphisms in alcoholics with severe medical complications versus those with less severe medical complications. There were no differences in allele and genotype frequencies of these two distinct genetic markers between alcoholics and control subjects in these five different ethnic groups. There was no significant linkage disequilibrium between the -141C polymorphism and two other DRD2 polymorphisms (TaqI A and NcoI). The results remained unchanged when cases were limited to alcoholics with more severe medical complications or when tobacco abusers were excluded from control subjects. The results suggest that both the DRD2 promoter region and the DAT gene do not play a significant role in conferring vulnerability to alcoholism.

Prolonged overexpansion of extracellular water in elderly patients with sepsis.

OBJECTIVE: To compare the sequential changes in extracellular water (ECW) expansion in elderly patients receiving intensive care for severe sepsis with those in a similar group of younger patients. DESIGN: Inception cohort study. SETTING: Critical Care Unit and University Department of Surgery in a single tertiary care center. PATIENTS: A consecutive series of 14 patients older than 60 years (n=8) or younger than 40 years (n=6) with severe sepsis who completed sequential measurements of body composition during a 21-day period. MAIN OUTCOME MEASURE: Sequential measurements of body composition including ECW by bromide dilution, total body water by tritium dilution, and fat-free body mass by dual-energy x-ray absorptiometry were performed during 21 days after resuscitation. Excess ECW was estimated from the difference between measured ECW and ECW predicted from fat-free body mass corrected to normal hydration. RESULTS: On the first study day, ECW was overexpanded by 9.05+/-1.87 L (mean+/-SEM) and 10.33+/-1.79 L in the young and elderly groups, respectively (P=.66). Whereas the young group excreted most of this excess ECW by day 5 (P=.008), the elderly group remained overexpanded until day 10 before mobilization of ECW occurred (P=.003). The changes over time of ECW excess were significantly different (P=.02 for group x time interaction). The elderly group required more prolonged inotropic (P=.009) and ventilatory (P=.004) support and remained in intensive care longer (P=.008) than the young group. CONCLUSIONS: The period of ECW expansion is more prolonged in elderly patients with sepsis and contributes to a poorer outcome from critical illness. This new finding is of fundamental importance to the treatment of elderly patients recovering from severe sepsis.

Histopathologic changes after pericardial patch tracheoplasty.

Pericardial patch tracheoplasty has been used for surgical correction of long-segment congenital tracheal stenosis caused by complete tracheal rings in infants. The case histories of 2 infants with descriptions of the histopathologic changes in their respective tracheas are presented. Complete reepithelialization of the graft site with ciliated pseudostratified columnar epithelium was found, suggesting the likelihood of normal mucociliary flow in the trachea. The pericardial patches were replaced by mature scar tissue in the graft site, establishing a functional tracheal lumen. Wound healing in the trachea is reviewed. Obstruction by exuberant granulation tissue is an ongoing concern. Pericardium continues to be an important option as graft material for tracheal reconstruction in infants with long-segment congenital tracheal stenosis.

Inflammatory diseases of the ear.

The inflammatory diseases of external and middle ear are one of the commonest conditions encountered by the pediatric physician. Inner ear inflammations are less common and need special and urgent attention. Special management in each case requires detailed history, examination, necessary investigations and appropriate referral to otolaryngologist when necessary. The article is aimed to help formulate a plan in managing the inflammatory conditions of ear. Otalgia constitutes the most prominent of the symptoms in external and middle ear inflammations whereas vertigo, tinnitus and sensory hearing loss form the symptom complex for inner ear infections. It is necessary to understand the basic pathophysiology of the inflammatory condition to be able to institute a targetted treatment. The audiometry impedance studies, microbiology of discharge and occasionally ABR and CT scan from the mainstay of investigative workup. The treatment is specific and based on the precise diagnosis. It often requires the help of an otolaryngologist. Decisions may have to be made with regards to the need for any surgical intervention particularly in acute otitis media, an external canal abscess or an acute mastoiditis. A case of chronic otitis media with facial palsy or vertigo (labyrinthitis being a possibility) needs urgent intervention.

Middle ear effusion in children.

Acute otitis media (AOM) and otitis media with effusion (OME) in children can present with a variety of middle ear effusions (MEE). Even though the character of the effusion may vary, the underlying pathogenesis is often similar. In the last decade, there has been an abundance of new information in the fields of immunobiology and immunochemistry to explain the chronicity of MEE. There are also studies examining the efficacy of vaccination and immunoprophylaxis for recurrent AOM. Diagnosis of otitis media (OM) in a child can be difficult but good visualization by pneumatic otoscopy improves the accuracy of diagnosis of OME. The development of increasing bacterial resistance to antimicrobial therapy reinforces the need to be more rational in treating AOM and OME. The variability of the natural history and the long term sequelae of OME makes medical management more difficult. All children with chronic MEE should have audiologic evaluation. Surgery is recommended should the condition be refractory to medical therapy or if the complications of MEE develop.

Schizophrenia: conceptual change in modern psychiatry.

Schizophrenia is perhaps the most devastating mental illness that psychiatrists must treat. Its chronic course with deteriorating consequences has been the focus of study throughout this century. This paper reviews the concept of schizophrenia, from fundamental Kraepelinian theory of 'dementia praecox' to biological correlates and explanation. Its causes, however, remain obscure and there were no appreciable changes in its treatment modality. A 'bio-psycho-social' model of care is emphasized, aiming at the prevention of deterioration of symptoms, functional impairment, disability and social handicap.