GHB-induced delirium: a case report and review of the literature of gamma hydroxybutyric acid.

We describe what we believe is the first psychiatric hospitalization due to GHB-induced delirium reported in the medical literature. We examine the use of the substance gamma hydroxybutyric acid (GHB) and describe the clinical findings in a patient who presented to an acute inpatient psychiatric unit with a chief complaint of feeling suicidal and a 1-year history of GHB use. A review of the literature and GHB's availability through the Internet are discussed.

Serum thyroglobulin levels in the diagnosis and follow-up of subacute 'painful' thyroiditis. A sequential study.

Serum thyroglobulin (Tg) levels were elevated in 92% of 38 patients with subacute "painful" thyroiditis in the early stage, independent of the extent of the disease and thyroid hormone concentrations. After two months of corticosteroid treatment, serum Tg levels were significantly decreased in 25 patients who could be rechecked, compared with the levels in the acute phase, although higher than those in our normal control subjects. Twelve of 25 patients underwent sequential measurements of Tg for three to four months, during the disease and after recovery. In ten the initially elevated values decreased rapidly to normal and were maintained for approximately 20 days. Then they rose gradually, peaked about 60 days after disease onset, then returned slowly and permanently to normal. In one patient who had a clinical relapse during the plateau phase, the Tg level also increased markedly and abruptly. Therefore, serial measurements of serum Tg can help in diagnosing and monitoring subacute "painful" thyroiditis.

Diagnostic and prognostic value of TPA in breast cancer.

Serum tissue polypeptide antigen (TPA) was measured by RIA in 151 female patients who had had mastectomies for breast cancer, in 30 patients with benign breast disease, and in 30 normal controls. The marker was elevated in 52 neoplastic patients (25 with metastases) and in six cases of benign breast disease. At the time of our observation 15 cancer patients were at stage I, 53 at stage II, 48 at stage III, and 35 at stage IV, the prevalence of high TPA values significantly correlated with staging gradually increasing from 0 to 71.4% from stage I to IV. In patients with breast cancer TPA was significantly higher in the subgroup with metastatic disease compared to patients with apparently inactive disease. Nineteen patients without (group A) and 35 with metastases (group B) were monitored with serial measurements of TPA for 8-24 months. Group B was receiving either hormone or chemotherapy. In 10 group A patients TPA was either higher or rose 1-7 months prior to the clinical detection of metastases. Twenty-two patients from Group B had disease progression: In 20 of them TPA rose further. The remaining 13 patients had an apparent disease regression, and in 11 instances TPA either fell or remained normal. Thus TPA can detect early recurrence of breast cancer before clinical and instrumental methods; moreover, it might prove important in evaluating tumor response to treatment and in follow-up of patients with metastatic disease. Finally, serial measurements of TPA could identify previous false-positive results, thus improving the specificity of the test.

The TRH induced PRL release in patients with autonomous thyroid nodules before and after surgical treatment.

Total and free thyroid hormones (T3, T4, FT3, FT4), TSH and PRL were determined in basal conditions and after stimulation with TRH in 32 patients affected by autonomous thyroid nodules before and after nodulectomy and in 24 control subjects. Only 7 patients were clinically thyrotoxic and thyroid hormone concentrations were slightly elevated in most cases. In untreated patients the increment (delta) in PRL after TRH was significantly lower than in normal subjects but was not as severely depressed as that of TSH. After nodulectomy both delta PRL and delta TSH increased and were not significantly different from those found in normal subjects. Thus PRL responsiveness to TRH is depressed by prolonged though moderate increases in thyroid hormone concentrations but is not as sensitive to their action as TSH.

Evaluation of peritoneovenous shunt patency with Tc-99m labeled microspheres.

The LeVeen peritoneovenous shunt (PVS) was investigated in 40 cirrhotic patients with refractory ascites. Five millicuries of Tc-99m-tagged human albumin microspheres (15-36 microns) were injected into the peritoneal cavity between the umbilicus and the left anterior superior iliac spine. The radiotracer was always detectable by scintigram in the lungs when the shunt was patent. In case of malfunction, by contrast, the radioactivity was either restricted to the venous tube or confined below the diaphragm for at least 4 hr. In the presence of complete obstruction, whereas the tube was not visualized after peritoneal injection, it was outlined by direct injection of 2 mCi of Tc-99m albumin microspheres into its subcutaneous tract, where it crossed the 12th rib, immediately above the valve. This technique sufficed to establish whether the site of obstruction was at the valve or in the tubing itself. In one patient, poor visualization of the tube and a delayed image of the lungs was caused by partial occlusion of the valve with fibrinoid debris. This radiotracer method proved simple, quick, and led to an immediate selective replacement when the shunt was not patent. Therefore, the use of this test is recommended for a definitive diagnosis, since there were neither false negatives nor false positives. No complications such as embolism or bacterial infection were encountered with Tc-99m human albumin microspheres, which are excellent tracers.

Role of 131Cs scan in preoperative diagnosis of nonfunctioning thyroid nodules.

The role of 131Cs scan in the preoperative diagnosis of cancer was evaluated in 355 patients with either cold or nonfunctioning thyroid nodules. Nodules were classified as positive, doubtful or negative by the pattern of isotope accumulation. Among 234 patients who underwent thyroidectomy, malignant lesions were found in 10.2 per cent of cases. All carcinomas but one found during surgery had been classified as positive by radiocesium scan and were considered as highly suspicious preoperatively; one carcinoma and two papillary adenomas had been classified doubtful and considered presumably malignant. False-positive nodules were found. However, we did not document histologically malignant lesions in nodules which were classified as negative by radiocesium uptake. The routine use of 131Cs scanning may be very useful in patients with cold or nonfunctioning thyroid nodules because of its high sensitivity in excluding malignant lesions.

Systolic time intervals in hyperthyroidism.

PEPI (pre-ejection period index), QS2I (total electromechanical systolic index), LVETI (left ventricular ejection time index), and PEP/LVET ratio were measured in 35 thyrotoxic patients. None of the patients had clinical evidence of heart disease nor received drugs which might have affected the systolic time intervals. the hyperthyroid subjects showed significant shortening of PEPI and significant reduction of PEP/LVET, which returned within normal limits when the patients became euthyroid during treatment. No correlation could be found between T3, T4, FTI and PEPI or PEP/LVET. However, serial measurements indicated that the fall toward the normal range of PEPI parallelled that of T3; the latter is considered the most important index of thyroid function. Our study suggests that PEPI and PEP/LVET ratio may be of great usefulness in detecting hemodynamic alterations in subjects with uncomplicated hyperthyroidism. Moreover, these methods may facilitate the diagnosis in unusual types of hyperthyroidism occurring in the absence of clinical signs of toxicosis. In addition, PEPI and PEP/LVET appear to be useful in detecting T3 toxicosis. Finally, serial controls of PEPI could represent a useful index to monitor the response to therapy.

Alteration of thyroid function in the early stage of subacute thyroiditis.

Measurement of serum triiodothyronine (T3), thyroxine (T4), free triiodothyronine (FT3), free thyroxine (FT4), thyroxine-binding-globulin (TGB), antithyroglobulin antibodies (anti-hTg), thyroid 131I uptake and scanning was performed on 12 patients during the early phase of subacute thyroiditis. Serum thyrotropin (TSH) was measured during baseline conditions and following administration of synthetic thyrotropin-releasing-hormone (TRH). The stimulation with exogenous TSH was performed on 7 subjects. 131I uptake was depressed in all patients including those with solitary nodules. Free and total hormone concentrations were elevated in the three cases with diffuse gland involvement, whereas an increase of T3 alone was present in 3 patients with unilobar involvement. In the latter group and in the 2 patients with a nodular form T4, FT3 and FT4 levels were within normal limits. Interruption of the pituitary-thyroid feed-back mechanism with absence of thyrotropin response to TRH occurred in 11 patients, independent of whether thyroid hormone concentrations were elevated or normal. In one patient only with unilateral involvement, TSH responsiveness to TRH was normal while 131I uptake was not raised by exogenous TSH, indicating diffuse cellular damage. The normal values of FT3 and FT4 found in patients with normal T3 and T4 levels seem to exclude the possibility that the free hormones are responsible for the interrupted feed-back which represents the main cause of suppressed iodine uptake. However, it is possible that the pituitary-thyroid axis is responding to transient or light increases of free and total T3 and T4 still within their 'normal range'.

Role of serum carcinoembryonic antigen in preoperative diagnosis of cancer in patients with thyroid nodules.

Serum carcinoembryonic antigen (CEA) was measured by double antibody radioimmunoassay technique in 95 normal subjects and in 258 patients with thyroid nodules. All the normal subjects and the patients with benign nodules had normal CEA values. Increased serum CEA levels (above 50 ng/ml) were found in all medullary and undifferentiated (giant cell) carcinomas. After surgery, the CEA fell within the normal range in the patients with medullary carcinoma. High levels of CEA were also present in 26% of differentiated carcinomas. A relationship between high CEA values and the presence of metastatic disease was not found. Measurement of serum carciniembryonic antigen may be useful in the preoperative diagnosis of cancer in patients with thyroid nodules.

Free thyroxine (FT4) and free triiodothyronine (FT3) in autonomous thyroid nodules.

Total and free thyroid hormones (T3, T4, FT3 and FT4), TSH and its response to TRH were determined in sixty-three patients affected by autonomous thyroid nodules: mean concentrations of free T3 (FT3) were significantly higher in hot nodules (suppressing extranodular tissue on the scan) as compared to warm ones, even in those cases where total T3 and T4 were within normal ranges (hot nodules, group as a whole: 8.8 +/- 3.5 pg/ml; warm nodules: 5.3 +/- 1.2; hot nodules with normal total T3 and T4 concentrations: 7.5 +/- 3). Also the clinical condition of thyrotoxicosis appeared to be correlated with FT3 concentrations (toxic patients, group as a whole: 9.6 +/- 4.0 pg/ml; euthyroid patients: 6.8 +/- 3.1; toxic patients with normal values of T3 and T4; 8.3 +/- 2.8). On the contrary the correlation of total and free thyroid hormone concentrations with the response of TSH to TRH was not significant.