Fentanyl and Sudden Death-A Postmortem Perspective for Diagnosing and Predicting Risk.

Sudden, unexpected deaths are extremely difficult for families, especially when the victim is a child. Most sudden deaths occur due to cardiovascular issues, and a smaller number (approximately one-quarter) are attributed to other causes, such as epilepsy. The medicinal and non-medicinal use of the synthetic opioid fentanyl, which can cause breathing problems, is frequently involved in these deaths. It is also being found more often in autopsies of sudden death cases, and the number of overdose deaths from illicit drugs containing fentanyl is increasing. There are cases in which it is mixed with other drugs. A gene known as the KCNH2 gene or human ether-a-go-go-related gene (hERG), involved in the heart's electrical activity, can be related to abnormal heart rhythms. This gene, along with others, may play a role in sudden deaths related to fentanyl use. In response, we have examined the scientific literature on genetic variations in the KCNH2 gene that can cause sudden death, the impact of fentanyl on this process, and the potential benefits of genetic testing for the victims to offer genetic counseling for their family members.

Predictors of Quality of Life in Patients with Drug Resistant Epilepsy after Neurosurgical Treatment: One-Year Follow-Up.

BACKGROUND: Invasive neurosurgical treatment or minimally invasive neurosurgical treatment are methods of choice for the treatment of patients with drug resistant epilepsy. The aim of this study was to evaluate the impact of neurosurgical treatment and the quality of life of patients with drug resistant epilepsy and to determine what are the potential predictors of quality of life of patients with drug resistant epilepsy one year after neurosurgical treatment. SUBJECTS AND METHODS: The research was performed at the Referral Centre for Epilepsy, Department of Neurology, University Hospital Centre Zagreb from February 2015 to February 2020 with Ethics commitee approval. The study included 96 patients with drug resistant epilepsy who were examined for the quality of life before and one year after neurosurgical treatment using the form questionnaire "Quality of life in epilepsy" (QOILE-31) validated Croatian 1.0 version and the questionnaire to assess the degree of depression "Beck Depression Inventory I" (BDI-I) validated Croatian version. RESULTS: Of 96 patients with drug resistant epilepsy one year after neurosurgical treatment 46 (47.9%) patients remained completely free from epileptis seizures. Wilcoxon equivalent pair test showed that the number of epileptic seizures one year after neurosurgical treatment was significantly lower (median before neurosurgical treatment is 10; and after neurosurgical treatment is 1, p<0.001). The most informative potential statistically significant predictor variables of quality of life based on the criterion variables QOLIE-31 and BDI-I are: total disease duration in years (p=0.034), patient age (p=0.042), number of antiepileptics one year after neurosurgical treatment (p=0.001), the number of epileptic seizures per month (p=0.016), and social welfare rights (p=0.045). CONCLUSION: Neurosurgical treatment of patients with drug resistant epilepsy significantly reduces the number of epileptic seizures which significantly improves their overall quality of life one year after neurosurgical treatment.

Quality of Life of Persons Suffering from Schizophrenia, Psoriasis and Physical Disabilities.

BACKGROUND: Studies have addressed the impact of chronic diseases and their treatment on quality of life (Qol), but the relative impact of different chronic conditions on patients' level of subjective functioning is mostly unknown. Stigma is associated with poor Qol in various chronic diseases. The aim of this study was to compare the quality of life of people suffering from schizophrenia with the quality of life of patients with psoriasis and physical disabilities. SUBJECTS AND METHODS: Study was conducted on a sample of 88 persons suffering from schizophrenia, 60 persons with physical disabilities and 57 persons with psoriasis. All three groups completed The Scale of Life-Quality assessment. RESULTS: Persons suffering from schizophrenia were less satisfied with their education level and social life. They were less satisfied with life if continued the same as present than persons with physical disabilities and people suffering from psoriasis. However, persons suffering from schizophrenia have higher expectations for the future than persons with physical disabilities and people suffering from psoriasis. CONCLUSIONS: Our results show lower quality of life in the group of patients with schizophrenia in comparisons with group with physical disabilities and psoriasis, which indicates that it is necessary, not only to make the treatment of schizophrenia more successful, but also to improve the process of rehabilitation and social reintegration in order to increase the quality of life of people with schizophrenia.

Effects of Psychosocial Day Care Programme on Quality of Life in Patients Affected with Schizophrenia - a Prospective Study.

BACKGROUND: The basic aim of this prospective research was to establish the effect of psychosocial day care programme on the therapy outcomes in patients with schizophrenia. SUBJECTS AND METHODS: While 115 patients with schizophrenia were invited to participate, 100 of them completed the study and were subdivided into two groups. In addition to pharmacotherapy, the experimental group only (N=50) was integrated into a day-hospital-based psychosocial day care programme. The instruments were applied in three phases: the first measurement for experimental group subjects took place on the first day of psychosocial day-care programme, while for the control group subjects the same was performed on the last day of inpatient care. The second measurement for the experimental group was performed in the end of psychosocial day-care programme, while for the control group patients it occurred four months after inpatient treatment. The third measurement was carried out six months after the second one. The following instruments were applied: General Demographic Questionnaire at the first measurement, Manchester Short Assessment of Quality of Life-MANSA both at the first and third measurement, and Positive and Negative Symptoms Scale-PANSS at all three measurements. RESULTS: Experimental group patients showed a statistically significant increase in quality of life outcomes as well as statistically significant decrease in positive symptoms and general psychopathology at all three measurements and with regard to the control group. As to the negative symptoms, only the third measurement revealed a statistically significant difference. CONCLUSION: The results obtained indicate that the adjuvant treatment of psychosocial day care programme has a positive effect on treatment outcomes: on the increase of the patients' quality of life, and, to some extent, on the decrease of symptom intensity in positive symptoms in schizophrenia spectrum. However, the effect of psychosocial day-care programme on the negative symptoms was proved to be considerably smaller.

Infections in Hospitalised Patients with Multiple Myeloma: Main Characteristics and Risk Factors.

OBJECTIVE: Multiple myeloma is a common haematological malignancy and immune dysfunction is the hallmark of the disease. It leads to an increased infection risk, which is still a major cause of mortality. The infection spectrum and characteristics have evolved with the introduction of novel agents. An understanding of risk factors that increase susceptibility to infections is critical in fighting them. This retrospective investigation aimed to establish the incidence and main characteristics of infections in non-transplanted hospitalised myeloma patients in our department over a 3-year period, as well as factors associated with infections. MATERIALS AND METHODS: A total of 240 hospitalised patients with multiple myeloma (120 males and 120 females; average age: 69 years, range: 41-89 years) who were diagnosed or treated in our department from January 2008 to December 2010 were included in this study and their data were retrospectively analysed. RESULTS: Infections were identified in 17.9% of hospitalised patients. The most common pathogen found was Pseudomonas aeruginosa. The frequency of gram-positive and gram-negative pathogens was similar. In 37.2% of cases, the agent was not isolated. The most common sites of infections were the urinary system and the blood (septicemia). The frequency of infection increased with duration of disease and the rate of reinfection was 41.9%. The patients treated with bortezomib had the highest infection occurrence. Fatal outcome occurred in 9.3% of cases. CONCLUSION: The factors associated with infections in this investigation were female sex, 3B clinical stage of disease, increased serum creatinine and ferritin levels, neutropenia, poor general condition, and presence of catheters. Myeloma patients with one or more of these mentioned risk factors should be monitored with particular care in order to decrease the incidence and severity of infective complications.

Less is more--possible option in the treatment of depression.

Depression is an illness of modern society, which affects population of different age. Etiological factors differ, and frustration factors as a cause of depression are multiplying. Each new episode presents difficulties, both for patients and psychiatrists. Despite the increasing number of antidepressants we use in treatment, it is sometimes hard to notice an efficient antidepressant in an optimal-efficient dose. In resistant cases we apply combinations of psychopharmacs, and the choice of the same depends on the leading symptoms. We will present the case of a 67-year-old patient where a depressive episode (in the terms of a reccurent major depressive disorder) lasts for one year. During this period she was treated as outpatient and inpatient with several antidepresants in combinations with other psychopharmacotherapeutical drugs. Despite regular treatment, mental state was worsening. Clinical presentation was indicating developing of dementia (behavior, cognition outges), which we excluded through diagnostic process. Psychopharmacological combinations (antidepresants, mood stabilizators, antypschotics, anxsiolotix) were not efficant. Progression of simptoms leads to rehospitalisation. In further treatmen, we followed the principle "Less is more" which resulted with an expected and satisfactory outcome.

The relationship between personality traits and anxiety/depression levels in different drug abusers' groups.

Aim. Since psychosocial characteristics of drug abuse involve mainly specific personality and emotional changes, it is very important to investigate characteristics of addictive personality in relationship with emotional state of the individual. Considering that, the objective of this study was to analyse the relationship between personality structure and emotional state of two different groups: heroin addicts and recreate drug abusers. Methods. The total of 288 (219 males and 69 females; 191 heroin addicts and 97 recreate drug users) clients of Centre for the prevention and treatment of drug abuse in Rijeka completed Eysenck's Personality Questionnaire (EPQ R/A), Beck's Anxiety Inventory (BAI) and Beck's Depression Inventory (BDI). Their average age was 22. Results. In the group of heroin addicts, higher levels of anxiety and depression were significantly correlated with higher levels of psychoticism, neuroticism, criminality and addiction. In the group of recreate drug users, higher extraversion and social conformity were determined. Furthermore, in the first group was found even higher depression. However when the anxiety level was compared between these two groups, there was no significant difference. Conclusion. Overall, the findings implied that the used measurement instruments could serve as the useful diagnostic tools that could ensure advantageous treatment directions.

Relations between the course of illness, family history of schizophrenia and family functioning in persons with schizophrenia.

The aims of this study were to identify the aspects of family functioning which are associated with the course and remission of schizophrenia and to explore relations between aspects of family functioning and family history of schizophrenia. The subjects were 90 patients, treated at the Clinical hospital centre in Rijeka, Croatia, with diagnosed schizophrenia (F20.0 to F20.5) and without psychiatric comorbidity. The patients were organized into three groups depending on the treatment status during the calendar year that preceded the year in which the survey took place: patients with schizophrenia who received an outpatient care and were maintaining favourable remission, patients who were hospitalized once to twice and patients who were hospitalized at least three times in the precedent calendar year. The treatment status was used as an indicator of the course of the illness. A Family Functioning Scale was applied and the data on the absence/presence of schizophrenia in the family history were collected through the examination of previous medical records. The lowest prevalence of familial schizophrenia was found among the patients who were maintaining favourable remission. Among the three groups statistically significant differences were found regarding the following family functioning variables: expressiveness, family sociability, democratic family style. Also there were observed statistically significant differences in the family functioning depending on the presence/absence of the schizophrenia in the family history that included following domains: family cohesion, external locus of control and democratic family style. Our study gives support to the conclusion that family functioning of persons with schizophrenia differs depending on the course of the illness and presence/absence of schizophrenia in the family history.

Proposal for a new detection method of substance abuse risk in Croatian adolescents.

One of the most important factors of successful substance abuse treatment is the early start of the same treatment. Recent selection method for identification of Croatian adolescents in the substance abuse risk that has been using drug tests from urine samples, has been simple and exact on the one hand, but on the other, has been very rare and usually guided by the pressure of parents or the court. Besides, such method presented the source of legal and ethical questions. So, the proposal of application of standardized psychological tests during systematic medical exams of Croatian adolescents at the age range of 15-22 years could help with the early detection of those adolescents who were in the substance abuse risk or already had the developed addiction problem.

Switching among antipsychotics--focus on side effects.

Depression is a disorder held responsible for high morbidity in the overall population. Causes of depression vary, but lifestyle and stress can greatly contribute to its morbidity. Consumption of antidepressants is showing a trend in the economically developed countries. Apart from antidepressants, the treatment of depression can consist of other psychopharmaca. Depending on the severity of a disorder, that is - of psychotic symptoms, antipsychotics can be introduced in the treatment. Among those atypical antipsychotics have an advantage. This paper will illustrate a course of treatment of a female patient, diagnosed with psychotic depression and treated with antipsychotics (i.e. olanzapine, ziprasidone), to which she developed side effects. To each of the antypsychotics the patient developed side effechts, causing in prolonged treatment and affected its course.

Hyperprolactinaemia with amisulpride.

Psychopharmaca are used in treatment of psychiatric illnesses and disorders, among other therapeutic possibilities. The choice of the psychopharmaca is determined by the specific psychopathology of the patient, within the diagnostic categories, according to the current classification of diseases and disorders. With the advances in pharmaco industry, the range of drugs used in the everyday clinical practice is occurring at a very rapid pace. Antipsychotic medications are used in treatment of mainly psychotic disorders. However, the new generation of antipsychotics, due to their specific receptor affinities, is sometimes used in treatment of affective disorders as well. We are reporting a case of a female patient who was hospitalized several times. Amisulpride was introduced in the treatment and due to a series of unfortunate events and changes that followed (i. e. frequent hospitalizations and changes of therapists, different mental institutions) dose of amisulpride was gradually increased to its antipsychotic doses, which did not help achieve therapeutic benefits, but serious side effects.

Treatment strategy in schizophrenia combined with eating disorder.

Like any other patient, a schizophrenic patient can get a physical illness, too. As such patients tend to ignore reality and neglect themselves and are stigmatized by society, due to which their physical symptomatology is often ignored, physical illness can remain undetected. If the schizophrenic patient is observed and adequate care is provided by the family, family doctor and a psychiatrist, it is possible to recognize the physical illness and intervene promptly. We are presenting a case of a female patient who has been treated for schizophrenia for a number of years. The treatment was mostly ambulatory (i.e. the patient was hospitalized twice) and consisted of first-generation antipsychotics. During the past two years, for reasons unknown, the patient stopped taking regular meals and as a result lost significant body weight, became apathetic and withdrawn, started avoiding social contacts and neglected personal hygiene. She reportedly took the psychopharmaca regularly, but rarely attended psychiatric follow-up consultations. Due to substantial weight loss and hypotonia, correction of antipsychotic was made and internist treatment administered. The choice of olanzapine was not an accidental one. We decided to take advantage of its side effect for the treatment of an anorectic syndrome. Interdisciplinary cooperation proved to be a justified decision.

Antipsychotic treatment--side-effect and/or metabolic syndrome.

According to current medical opinion chronic mental diseases such as schizophrenia require life-long treatment. The choice of antipsychotics is an important treatment factor, since their side-effects often influence patients' compliance with treatment. Severe side-effects may cause the patients to reject such treatment, the latter being their right. In case a psychiatrist does not agree with the patient's decision to interrupt his antipsychotic treatment regardless its serious side-effects, the former should be persistent in convincing the patient to replace such drug with a more appropriate therapy.

Weight gain induced with olanzapine in adolescent.

Children and adolescents are being treated with antipsychotics more often than before, although the risk of adverse events in this age group still remains unclear. Because of increased use of antipsychotics in children and adolescents, their endocrine and metabolic side-effects (weight gain, obesity, and related metabolic deviations) are of particular worrying, especially within pediatric and adolescent population that appears to be at greater risk comparing with adults for antipsychotic-induced metabolic adverse events. In this work we will present the course of treatment of an adolescent girl with psychotic symptoms, within the clinical diagnosis of Organic delusional disorder, who had a considerable weight gain after one year of olanzapine treatment.

Weight gain--as possible predictor of metabolic syndrome.

Rapid weight gain among patients with mental disorders can further compound psychological distress and negatively influence compliance. Weight gain associated with treatment with atypical antipsychotic medication has been widely recognized as a risk factor for the development of diabetes type II and cardiovascular diseases. This paper describes a 33-year old female patient treated for schizoaffective disorder. Within two months after introducing quetiapine the patient experienced considerable weight gain amounting to 19 kg. The replacement of antipsychotic during inpatient psychiatric care resulted in weight loss.

Lamotrigine treatment of a patient affected by epilepsy and anxiety disorder.

Epilepsy often occurs in comorbidity with mental diseases and disorders. Early detection and/or treatment of such disorders in patients affected by epilepsy, as well as their socialisation are crucially important since epileptic patients tend to suffer more due to lack of social support than to frequent epileptic seizures. Prevalence of psychiatric disorders is higher in patients with epilepsy than in general population, the most frequent being: anxiety, depression, panic attacks, behavioural disorders as well as psychotic states with paranoid elements. The efficacy of AE treatment of patients affected by epilepsy and mood disorders has also directed clinicians to investigate possible AE benefits in treating other mental disorders such as anxiety states, depression and bipolar disorder. The examined case displays complex partial epilepsy and comorbid mental disorder. The use of lamotrigine, a fourth-generation antiepileptic, which is also a mood stabilizer, has assured a favourable remission of symptoms related to both epilepsy and mood disorders. Side-effects caused by lamotrigine were only temporary and dose reduction was sufficient to eliminate their symptoms.

Allergic reactions--outcome of sertraline and escitalopram treatments.

The treatment of dysthymia in itself poses a problem in the everyday psychiatric practice and it can be further hindered when accompanied by pronounced personality traits (which are indicative of disorder). Due to its pathology and duration dysthymia interferes with the patient's quality of life and the ability to function in some segments of everyday life. These interferences enticed our patient to opt for psychiatric treatment. During a three-year period, despite all the efforts made by psychiatrists in this comprehensive and challenging dysthymia treatment (psychotherapy, group psychotherapy, psychopharmacotherapy), the expected outcomes of the treatment did not occur. The patient's goals and expectations included lifestyle change, achieving life satisfaction and mood improvement. The patient was refusing suggested psychopharmaca until confronted, in psychotherapy, with the fact that she is the one prolonging her own helplessness and directing her passive agression at the members of the group. In the end the patent agreed to take psychopharmaca. Therefore, sertraline was introduced in the treatment, but the patient experienced a severe allergic reaction (Qiuncke's oedema). After four months the second attempt was made and escitaloptam was introduced, which resulted in urticaria. Due to these allergic reactions to antidepressants, the patient decided not to pursue the psychopharmacological treatment.

Changes in life-quality, a possible symptom of dementia development.

Dementia is a chronic and irreversible brain impairment characterised by significant cognitive deficits. Severe symptoms of the aforesaid disease interfere with normal life functions and daily activities. Dementia usually develops with advancing age, i.e. after the age of 85, and when it develops in people younger than age 65, it is referred to as early onset dementia. This paper presents a 53-year-old male patient. Provisional diagnosis was established while further diagnostic workup included psycho-diagnostic assessment, neurological exam, and brain CT Such workup confirmed the development of dementia, i.e. early-onset Alzheimer's disease accompanied by depressed mood with impaired vision.