Testicular torsion and subsequent testicular function in young men from the general population.

STUDY QUESTION: Is prior testicular torsion associated with testicular function (semen quality and reproductive hormones) in young men from the general population? SUMMARY ANSWER: In young men from the general population, no differences in semen parameters were observed in those who had experienced testicular torsion compared to controls and observations of higher FSH and lower inhibin B were subtle. WHAT IS KNOWN ALREADY: Testicular function may be impaired after testicular torsion, but knowledge is sparse and based on studies with small sample sizes and no control group or a less than ideal control group. STUDY DESIGN, SIZE, DURATION: A cross-sectional population-based study was carried out including 7876 young Danish men with unknown fertility potential, examined from 1996 to 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS: All men (median age 19.0 years) had a physical examination, provided a blood and semen sample, and filled in a questionnaire including information about prior testicular torsion, birth, lifestyle and current and previous diseases. Markers of testicular function, including testis volume, semen parameters and reproductive hormones, were compared between men operated for testicular torsion and controls, using multiple linear regression analyses. MAIN RESULTS AND THE ROLE OF CHANCE: The average participation rate was 24% for the entire study period. In total, 57 men (0.72%) were previously operated for testicular torsion (median age at surgery 13.4 years) of which five had only one remaining testicle. Men with prior testicular torsion were more often born preterm (25% versus 9.5% among controls), and they had significantly higher FSH and lower inhibin B levels, and a lower inhibin B/FSH ratio than controls in crude and adjusted models. The association was mainly driven by the subgroup of men who had undergone unilateral orchiectomy. No differences in semen parameters were observed. LIMITATIONS, REASONS FOR CAUTION: A limitation is the retrospective self-reported information on testicular torsion. Also, results should be interpreted with caution owing to the high uncertainty of the observed differences. WIDER IMPLICATIONS OF THE FINDINGS: Overall, the results of our study are reassuring for men who have experienced testicular torsion, especially when treated with orchiopexy, for whom reproductive hormone alterations were subtle and without obvious clinical relevance. Our study found no differences in semen parameters, but follow-up studies are needed to assess any long-term consequences for fertility. STUDY FUNDING/COMPETING INTEREST(S): Financial support was received from the Danish Ministry of Health; the Danish Environmental Protection Agency; the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603, FP7/2007-2013, DEER Grant agreement no. 212844); A.P. Møller and wife Chastine Mckinney Møllers Foundation; Svend Andersens Foundation; the Research Fund of the Capital Region of Denmark; and ReproUnion (EU/Interreg). The authors have nothing to declare. TRIAL REGISTRATION NUMBER: N/A.

Ethnocultural allodynia.

The authors introduce and define ethnocultural allodynia as an abnormally increased sensitivity to relatively innocuous or neutral stimuli resulting from previous exposure to painful culturally based situations. Ethnocultural, gender-specific, and cognitive-behavioral techniques are used in clinical vignettes to illustrate the pervasive ethnic, racial, and gender effects of ethnocultural allodynia in the lives of people of color. Therapy components for the treatment of ethnocultural allodynia are described, including psychoeducation regarding racism and its sequelae, racial socialization, inoculation, and racial stress management.

Donepezil for psychotropic-induced memory loss.

BACKGROUND: Donepezil is an acetylcholinesterase inhibitor marketed for treatment of memory loss and behavioral deterioration associated with the acetylcholine deficit of Alzheimer's disease. We investigated the utility and tolerability of donepezil in nongeriatric affective illness for treatment of psychotropic-induced memory loss, dry mouth, and constipation. METHOD: Nondemented outpatients with stabilized DSM-IV affective illness took 5 mg/day of donepezil for 3 weeks and then increased to 10 mg/day in open trials. Self-rating scales of target symptoms were completed by patients before and 3 to 4 weeks after starting each dose condition. Patients who chose to continue donepezil therapy returned for clinical monitoring every 4 to 8 weeks. RESULTS: Eleven women and 11 men (mean +/- SD age = 45.4+/-8.5 years) completed donepezil trials. Nineteen patients with memory loss rated improvement while taking 5 mg/day of donepezil (p<.001); subsequently, 6 rated further improvement with 10 mg/day (p = .057). Donepezil, 5 mg/day, also reduced ratings of dry mouth (N = 16; p<.001) and constipation (N = 11; p<.05). Side effects included insomnia, nausea, vomiting, and diarrhea; surprisingly, 2 bipolar patients became manic within hours of starting donepezil. Sixteen patients (72%) continued donepezil for an average of 7 months. Consideration of family histories suggested that donepezil response in affective illness may be an early indicator of vulnerability to dementia of the Alzheimer's type. CONCLUSION: (1) Donepezil can reduce memory loss, dry mouth, and constipation in nongeriatric affective patients, but may trigger mania; and (2) long-term follow-up will reveal the predictive value for dementia of donepezil's memory restoration in nongeriatric subjects.

Risperidone in the treatment of affective illness and obsessive-compulsive disorder.

BACKGROUND: Risperidone is a new-generation atypical antipsychotic agent with potent dopaminergic and serotonergic antagonist activity. Compared with traditional dopamine-blocking neuroleptics, risperidone is more effective in treating negative symptoms of schizophrenia and may be less likely to cause extrapyramidal symptoms or tardive dyskinesia. Although risperidone is marketed for the treatment of schizophrenia, its novel psychopharmacologic effects and potentially mild side effect profile suggest the possibility of other therapeutic applications. An open prospective study was undertaken to determine whether risperidone might diminish psychosis, severe agitation, or rapid cycling in patients having acute and chronic primary affective illnesses (bipolar and major depressive disorder) and to document response characteristics and side effects. Additionally, a small number of patients with refractory obsessive-compulsive disorder (OCD) without comorbid tic or delusional disorders were given open trials of risperidone added to their medication. METHOD: Outpatients who fulfilled DSM-IV criteria for bipolar I, bipolar II, or major depressive disorder and suffered from psychosis or agitation associated with their illness (N = 20) and those who had treatment-refractory DSM-IV OCD (N = 5) were started on open trials of risperidone at daily doses of 1 to 1.5 mg. Doses were adjusted upwards to a maximum of 6 mg depending on clinical response. RESULTS: Seventeen (85%) of 20 patients (13 bipolar, 4 major depressive disorder) showed complete or partial improvement after treatment with risperidone doses ranging from 1 to 6 mg/day (mean = 3.5 mg). Beneficial effects included decreases in agitation, psychosis, sleep disturbance, and rapid cycling. Four patients (20%) discontinued risperidone because of intolerable side effects. Five patients with refractory OCD also showed significant symptomatic improvement after the addition of risperidone. CONCLUSION: The findings suggest that (1) risperidone may be useful in the acute/p.r.n. and chronic treatment of psychosis, agitation, and cycling accompanying affective illness, and (2) risperidone may be useful in augmenting pharmacologic response in OCD.

Hormonal responses to the administration of m-chlorophenylpiperazine in patients with seasonal affective disorder and controls.

We report on the plasma cortisol and prolactin responses to the serotonergic agonist m-CPP (0.1 mg/kg) in 10 patients with winter seasonal affective disorder (SAD) and 10 controls during the winter, in both untreated and bright light-treated conditions; and on 8 other SAD patients and 8 other controls during the summer. Following m-CPP infusion, untreated patients had exaggerated prolactin (p < .05) and cortisol (p < .05) responses compared to controls. Light treatment significantly reduced responses of both hormones to m-CPP (prolactin: p < .01; cortisol: p < .01). When untreated winter subjects and summer subjects were compared, cortisol, but not prolactin responses to m-CPP were found to be higher in patients than in controls during the winter, and lower in patients than in controls during the summer (diagnosis by season: p < .05). These results are consistent with those of our previous report on the behavioral responses to m-CPP in the same patients and suggest an abnormality in serotonergic function in untreated SAD patients in winter, which is normalized following treatment with light therapy and naturally during the summer.

Can psychotropic medications change ethnoculturally determined behavior?

A clinical case is presented in which the use of a prescribed psychotropic medication was associated with dramatic changes in ethnoculturally determined attitudes and behavior. These changes were first noticed by the patient and followed a month of improvement in the target symptoms for which the medication was prescribed. The hypothesis is advanced that changes in identity may occur only after the establishment and adjustment to a new neurohormonal equilibrium. Medication-induced personality changes may facilitate changes in ethnocultural identity.

The therapist of color and the white patient dyad: contradictions and recognitions.

The therapist of color and White patient dyad often involves contradictions and recognitions which are acknowledged through the specific processes and dynamics permeating this dyad. The relationship between self and other is frequently mediated through projection and identification. This article examines this unique interracial and interethnic therapeutic dyad emphasizing its clinical implications through the attribution of otherness, the use of colored screen projection, and the significance of power reversal. Special emphasis is given to the prevalent transferential and countertransferential reactions aided by clinical material. It is concluded that this therapeutic dyad provides a model for cross-cultural encounters where the resolution of contradictions can lead to the recognition of paradoxes, the acknowledgment of ambivalence, and the acceptance of disparate parts of the self.

Behavioral responses to intravenous meta-chlorophenylpiperazine in patients with seasonal affective disorder and control subjects before and after phototherapy.

A comparison of the baseline and post-infusion effects of the serotonin agonist meta-chlorophenylpiperazine (m-CPP) in 10 patients with seasonal affective disorder (SAD) and 11 healthy control subjects revealed significantly different subjective response profiles between the groups. Several baseline and m-CPP-stimulated responses in symptoms putatively related to serotonergic function changed significantly after a week's exposure to phototherapy in the SAD patients but not the control subjects. Before phototherapy, depressed patients with SAD reported activation-euphoria responses to m-CPP and significant decreases in carbohydrate hunger, but insignificant changes in feeling slowed or sleepy, while control subjects reported no mood or appetite changes but significant increases in feeling slowed down following m-CPP. After phototherapy, which led to a significant reduction in baseline depressive symptom rating to near-euthymic levels in the SAD patients, almost all of the patients' responses to m-CPP were normalized and no longer differed from the control subjects' responses. These results provide evidence of a possible dysregulation in serotonergic neurotransmission in depressed SAD patients that normalizes following treatment with phototherapy.

Sleep in fall/winter seasonal affective disorder: effects of light and changing seasons.

Disturbances of sleep are a hallmark of seasonal affective disorders (SAD), as they are of other mood disorders. Fall/winter SAD patients most often report hypersomnia. Among responses of 293 SAD patients on a symptom questionnaire, complaints of winter hypersomnia (80%) greatly exceeded insomnia (10%), hypersomnia plus insomnia (5%), or no sleep difficulty (5%). Increased sleep length in fall/winter is not unique to SAD. Among 1571 individuals across four latitudes surveyed at random from the general population, winter sleep increases of < or = 2 hr/day relative to summer were reported by nearly half. However, hypersomnia had a low correlation (r = 0.29) with the total number of other SAD symptoms that were reported in this sample. Ten SAD patients kept daily sleep logs across 1 yr that showed increases in fall and winter (sleeping most in October; least in May) whose maximum averaged 2.7 hr per day more weekend sleep than in spring and summer. These winter increases might have been somewhat attenuated since most received light therapy during part of the winter. Nocturnal EEG recordings of depressed SAD patients in winter showed decreased sleep efficiency, decreased delta sleep percentage, and increased REM density (but normal REM latency) in comparison with recordings: (1) from themselves in summer; (2) from themselves after > or = 9 days of light therapy; or (3) from age- and gender-matched healthy controls. Thus, the extent of fall/winter oversleeping recorded by our SAD patients did not differ dramatically from that reported by the general population, but sleep complaints of our SAD patients have been accompanied by features of sleep architecture that are different from healthy controls and are reversed by summer or by bright-light therapy.

Low-dose valproate: a new treatment for cyclothymia, mild rapid cycling disorders, and premenstrual syndrome.

BACKGROUND: Valproate has proved useful in the treatment of manic-depressive and schizoaffective disorders, usually in daily doses above 500 mg with corresponding blood levels in the range established for treatment of epilepsy (50-100 micrograms/mL). Since milder bipolar disorders may be more prevalent than bipolar I disorder, a prospective study was undertaken to determine whether lower doses of valproate might be useful for stabilization of mood cycling in patients having primary diagnoses of cyclothymia or rapid cycling bipolar II disorder. Additionally, open trials of low-dose valproate were conducted in a small number of women complaining of premenstrual syndrome. METHOD: Over a 3-year period, outpatients with non-menstrually-related rapid cycling who had fulfilled DSM-III-R criteria for cyclothymia or bipolar II disorder were started on open trials of valproate at daily doses of 125 or 250 mg. Doses were adjusted upward on approximately a monthly basis depending upon clinical response, and valproate blood levels were obtained. RESULTS: Twenty-six (79%) of 33 patients (15 cyclothymics, 11 bipolar II) reported sustained partial or complete stabilization of mood cycling with valproate doses ranging from 125 to 500 mg (mean = 351.0 mg) corresponding to serum valproate levels (mean = 32.5 micrograms/mL) substantially below the current recommended range. Cyclothymics required significantly lower doses and blood levels of valproate than patients with bipolar II disorder for stabilization of mood. Five patients (all bipolar II) failed to respond fully to low doses of valproate but improved with higher doses corresponding to blood levels in the 50 to 100 micrograms/mL range. Two patients had poor responses to valproate or intolerable side effects. In contrast to bipolar spectrum patients, only three (38%) of eight women with menstrually related cycling of mood reported good responses to low doses of valproate, while five reported no response to valproate. CONCLUSION: The findings suggest that (1) low-dose valproate may be useful in the treatment of cyclothymia and milder rapid cycling bipolar disorders and (2) there may be a correlation between the severity of bipolar disorder and the blood level of valproate required for stabilization such that milder forms of bipolar cycling require lower doses of valproate.

Seasonal variation in behavioral responses to m-CPP in patients with seasonal affective disorder and controls.

This paper reports the behavioral responses to m-chlorophenylpiperazine (m-CPP), a serotonin agonist, in patients with seasonal affective disorder (SAD) and controls during the summer. Results are compared with the responses of SAD patients and controls given m-CPP in the winter. Results of the winter study were reported earlier by our group. Baseline Hamilton depression ratings in SAD patients were significantly lower in the summer than in winter (p < 0.05). Additionally, in both SAD patients and controls, there were seasonal differences on the National Institute of Mental Health (NIMH) self-rating scale items: "depressed affect," "dysphoria," and "functional deficit" at baseline. The behavioral responses to m-CPP across seasons differentiated patients from normals only in the "activation/euphoria" item, on which a far greater response was seen in patients than in controls during the winter. This behavioral response may be a state marker for winter depression, as it was significantly reduced after light treatment of these patients in the winter, and in the summer. SAD patients responded differently from controls on "altered self-awareness" and "dysphoria" independently of seasons, and these responses may be considered as possible trait markers for this condition. These results provide further evidence of a possible deficiency in serotonergic transmission in seasonal affective disorder.

Fluoxetine-induced sexual dysfunction and an open trial of yohimbine.

BACKGROUND: Reports of fluoxetine-induced sexual dysfunction have described orgasmic and erectile difficulties but have neglected possible changes in sexual desire. This prospective study was undertaken to determine the percentages of patients experiencing different types of sexual dysfunction after successful antidepressant treatment with standard doses of fluoxetine. Additionally, an open trial of the alpha 2-adrenoceptor blocker yohimbine as a potential treatment for fluoxetine-induced sexual dysfunction was conducted in nine patients. METHOD: Over a 2-year period, outpatients who had fulfilled DSM-III-R criteria for major depression and subsequently responded to treatment with fluoxetine 20-40 mg were asked to report and describe changes in sexual function. A small number of consecutive nongeriatric patients complaining of new onset sexual dysfunction were invited to participate in an open trial of yohimbine 5.4 mg t.i.d. RESULTS: Fifty-four (34%) of 160 outpatients reported the onset of sexual dysfunction after successful treatment with fluoxetine: 16 (10%) of the 160 patients reported decreased libido, 21 (13%) patients reported decreased sexual response, and 17 (11%) patients reported declines in both areas. Eight of nine patients reported improvement in sexual function with yohimbine, although five patients reported side effects that led to discontinuation in two cases. CONCLUSION: These findings suggest that (1) fluoxetine-induced sexual dysfunction may include decreased sexual desire as well as decreased physical functioning and may occur more frequently than previously appreciated and (2) fluoxetine-induced sexual dysfunction may be treatable with yohimbine.

Predictors of response to phototherapy in seasonal affective disorder.

We examined data from 44 women with seasonal affective disorder (SAD) to determine whether any demographic, diagnostic, or symptomatic characteristics would be predictive of a favorable response to phototherapy. Preexistent hypersomnia was particularly associated with lessening of depression after phototherapy. In contrast to a report elsewhere, both "typical" and "atypical" depressive symptoms correlated with improvement after phototherapy.

Ethnocultural transference and countertransference in the therapeutic dyad.

The relevance and validity of ethnocultural factors in transference and countertransference reactions are proposed. Some of those prevalent in dyadic psychotherapy are described, focusing on intra-ethnic and inter-ethnic dyads. Case vignettes are presented to illustrate the ways in which ethnocultural factors serve as catalysts for such major therapeutic issues as trust, ambivalence, anger, and acceptance of disparate parts of the self.

Possible augmentation of antidepressant response by buspirone.

In open trials, seven of eight antidepressant nonresponders reported partial or full antidepressant response after the addition of buspirone 10 mg t.i.d. An additional eight of nine patients who suffered winter relapses of depression while receiving previously effective antidepressant regimens showed remission of depressive symptoms after the addition of buspirone 10 mg t.i.d. Improvement after the addition of buspirone was maintained for at least 3 months, and side effects were minimal in most patients. These results suggest that low doses of buspirone may be useful in augmenting antidepressant response.

Low-dose trazodone as a hypnotic in patients treated with MAOIs and other psychotropics: a pilot study.

In open trials, 20 of 21 patients with major depression who developed insomnia during treatment with monoamine oxidase inhibitors (MAOIs) reported sustained hypnotic effects from trazodone 50 to 75 mg. Similarly, 26 of 27 mood disorder patients with insomnia unrelated to MAOIs reported improved sleep with low-dose trazodone. No negative interactions with MAOIs and other psychotropics were observed, side effects were minimal, and no tolerance to the hypnotic effects of trazodone occurred. Low-dose trazodone may be a safe and effective agent for treating MAOI-induced and other insomnias.

Evidence for a decline with age in behavioral responsivity to the serotonin agonist, m-chlorophenylpiperazine, in healthy human subjects.

The functional significance of alterations in brain serotonin (5HT) associated with normal aging in both animals and humans is largely unknown. Using the effects of the 5HT agonist, m-chlorophenylpiperazine (m-CPP), as a measure of central serotonergic responsivity, we compared the behavioral and neuroendocrine responses of older normal volunteers (mean age +/- SD = 62.4 +/- 4.12) to those of younger normal volunteers (mean age +/- SD = 31.6 +/- 5.52). When m-CPP was administered intravenously, older subjects showed decreased behavioral responses but similar neuroendocrine responses, compared to younger subjects. The decreased behavioral responsivity was unrelated to pharmaco-kinetic differences between the groups, since m-CPP plasma levels were similar in both groups. This report is the first in vivo study in humans to demonstrate decreased behavioral responsivity with age following serotonergic stimulation, and may indicate a functionally less responsive 5HT subsystem in older subjects.