Clinical utility of neutrophil-lymphocyte ratio in the diagnosis of neuroleptic malignant syndrome.

Background: Neuroleptic malignant syndrome (NMS) is a life-threatening side effect of antipsychotic medication. In this study, we aimed to investigate the hypothesis of inflammation via neutrophil-lymphocyte ratio (NLR) in the etiology of NMS. Methods: In this retrospective case-control study, data were collected using digital database of Bakirköy Mental Health Research and Training State Hospital by screening NMS diagnosis according to 'International Classification of Diseases (ICD-10) code: G21.0' between the years of 2007 and 2017. We included 32 hospitalizations with the diagnosis of NMS and 31 other acute psychiatric hospitalizations without NMS of same patients. NLR was calculated as proportion of absolute neutrophil count to absolute lymphocyte count. Significance level was accepted as p < .05. Results: The mean NLR value of NMS group was 9.55 ± 5.13 and control group was 2.06 ± 0.71 (p < .001). According to ROC analysis in our study group, we found a mean NLR cutoff value ≥4 and lymphocyte percent cutoff of ≤18.4% have the probability of correctly identifying patients with NMS with the 100% sensitivity and 100% specificity. Conclusions: In this retrospective study, we considered that higher NLR value in NMS episode might be a resemblance of systemic inflammatory state. In addition, our results suggest that both NLR and lymphocyte percentage may be alternative minor criteria which are more sensitive and specific than leukocyte levels and CPK.

Serum osmolarity and blood viscosity as a potential explanation for the pathophysiology of neuroleptic malignant syndrome.

Background: Neuroleptic malignant syndrome (NMS) is a rare but life-threatening side effect. NMS patients usually develop dehydration and fluid-electrolyte imbalance. In this study, we aimed to investigate serum osmolarity and blood viscosity in patients with NMS.Methods: This was a retrospective case-control study including 32 admissions of 27 patients with the diagnosis of NMS. As a control group, 31 non-NMS episodes of hospitalizations of the same patients were included.Results: Serum osmolarity of NMS group was 301.83 ± 20.27 mOsm/L and control group was 294.20 ± 5.92 mOsm/L. Serum osmolarity of NMS group was statistically significantly higher than the controls (p = .018). Whole blood viscosity (WBV) at high shear rate (HSR) value of NMS group was 16.17 ± 1.48 and control group was 16.50 ± 1.38 (p = .331). Regarding WBV at low shear rate (LSR) values, also no statistically significant difference was observed between groups. LSR values of NMS and control group were 39.86 ± 30.11 and 47.41 ± 28.43, respectively (p = .387).Conclusions: Our findings indicate that serum osmolarity of NMS group was statistically significantly higher than the controls. In terms of blood viscosity, there was no statistically significant difference between groups. Higher serum osmolarity in NMS patients than controls may be a reflection of a relative hemoconcentration in NMS.KEY POINTSNMS is usually associated with dehydration resulting in fluid-electrolyte imbalance.We compared the NMS episodes with non-NMS hospitalizations (as control group) of the same patients.Serum osmolarity was statistically significantly higher in NMS group than the controls.There was no statistically significant difference between groups in terms of blood viscosity.

The alteration of retinal nerve fibre layer thickness with repetitive transcranial magnetic stimulation in patients with treatment resistant major depression.

OBJECTIVE: The nerves and axons of the retinal nerve fibre layer (RNFL) are similar to those in the brain and therefore retina is considered as the extension of the brain. We aimed to evaluate the RNFL thickness in the treatment-resistant major depressive patients before and after repetitive transcranial magnetic stimulation (rTMS) treatment and at least 6 months later after rTMS treatment using optical coherence tomography (OCT). METHODS: Thirty patients with treatment resistant major depression and 24 healthy controls were included in the study. rTMS was applied to the left dorsolateral prefrontal cortex (DLPFC) of the patients. RESULTS: rTMS was initiated in 28 patients. OCT assessments were performed in 24 patients at baseline and after rTMS treatment and in 19 patients at least sixth months after the rTMS treatment. We found significant increase in RNFL thickness compared with controls at the baseline and further increase in RNFL thickness after rTMS treatment. Although there was a decreasing trend in RNFL thickness 6 months after rTMS treatment, 6 months later RNFL thickness was still higher compared with controls. CONCLUSIONS: RNFL thickness is increased in treatment resistant major depression and rTMS over the left DLPFC further increases RNFL thickness in treatment resistant major depressive patients.

Thioredoxin is not a marker for treatment-resistance depression but associated with cognitive function: An rTMS study.

Elevated oxidative stress is known to play an important role in development of depression and cognitive dysfunction. To date, thioredoxin (TRX), an antioxidant protein, has been investigated as a marker for psychiatric disorders such as schizophrenia, bipolar disorder and autism but its relationship with depression is yet to be unknown. The aim of this study is to detect the TRX levels in patients with treatment-resistant depression (TRD), analyse the effect of rTMS (repetitive transcranial magnetic stimulation) application on TRX levels and display the relationship of TRX with cognitive areas. This study included 27 treatment-resistant unipolar depression patients and 29 healthy subjects. Patients were evaluated by Hamilton Depression Scale (HDRS), Hamilton Anxiety Scale (HARS) and Montreal Cognitive Assessment (MoCA) before and after rTMS application. 23 of TRD patients were applied high-frequency rTMS over left DLPFC for 2 to 4weeks and plasma TRX levels of patients and healthy subjects were measured. No significant difference was determined between the TRX levels of patients and healthy subjects (p>0.05). After rTMS application there were significant decrease in severity of depression (p<0.001) and anxiety (p<0.001), and explicit improvement in cognitive areas (delayed memory, visual-spatial/executive abilities and language points) (all p<0.05). No difference was detected in TRX levels of the patients after rTMS application (p>0.005). High language scores of the patients were found to be associated with high TRX levels (p<0.005). Our study indicates that TRX levels cannot be used as a marker for TRD or rTMS treatment in TRD. In spite of this TRX levels have a positive correlation with language functions of the patients of TRD. More extensive studies are required to clarify the mechanism of action of TRX and the effect of TRX on cognitive functions.

Serum osmolarity in male patients with bipolar disorder manic episode.

NEW FINDINGS: What is the central question of this study? The main goal of this study was, for the first time, to investigate the role of the serum osmolarity in bipolar disorder manic episode. What is the main finding and its importance? Our results demonstrate a diminished serum osmolarity in manic episode compared with healthy control subjects. This finding supports the hypothesis of a fluid and electrolyte imbalance during acute episodes. Decreased serum osmolarity might be a reflection of a relative haemodilution in mania. Imbalance of water and electrolyte homeostasis has been suggested to be associated with acute episodes of bipolar disorder. In this study, we aimed to investigate, for the first time, the serum osmolarity in bipolar disorder manic episode. A total of 68 bipolar inpatients in manic episode and 60 age- and sex-matched healthy control subjects were included in the study. Serum osmolarity was calculated from sodium (Na+ ), glucose and blood urea nitrogen (BUN) according to following formula: (2 × Na+ ) + (BUN/2.8) + (glucose/18). The significance level was accepted as P < 0.05. The serum osmolarity of manic patients was 295.34 ± 4.90 mosmol/l and that of the control group was 298.46 ± 5.33 mosmol/l. The serum osmolarity of the manic group was significantly lower than that of control subjects (P < 0.001). When we compared the components of serum osmolarity, a statistically significant difference was also observed between groups in terms of glucose (85.85 ± 12.25 mg/dl for manic, 92.95 ± 20.77 mg/dl for control subjects, P = 0.019) and Na+ (140.73 ± 2.06 mmol/l for manic, 142.06 ± 2.48 mmol/l for control subjects, P = 0.001). For BUN concentrations, there was no statistically significant difference between manic (25.50 ± 9.85 mg/dl) and control (26.61 ± 6.64 mg/dl) groups (P = 0.461). Our results demonstrate a diminished serum osmolarity in manic episode compared with healthy control subjects. This finding supports the hypothesis of a fluid and electrolyte imbalance during acute episodes. Decreased serum osmolarity might be a reflection of a relative haemodilution in mania. However, exploration of the role of fluid and electrolyte homeostasis and mechanisms of related hormones may contribute to a better understanding of the aetiology of bipolar disorder.

Assessment of cardiovascular risk via atherogenic indices in patients with bipolar disorder manic episode and alterations with treatment.

OBJECTIVES: Cardiovascular disease is one of the important cause of mortality among patients with Bipolar Disorder. Castelli Risk index I and II (CRI-I and II), Atherogenic Index of Plasma (AIP) and Atherogenic coefficient (AC) are new parameters in assessing cardiovascular risk. In this study we aimed to explore the status of cardiovascular risk factors and their alterations with treatment in manic episode. METHODS: Bipolar Disorder inpatients who were in manic episode and age-gender matched healthy controls were included in the study. CRI-I, CRI-II, AIP and AC parameters were calculated before and after treatment. The statistical significance level was accepted as p<0.05. RESULTS: Sixty-eight male patients and 60 healthy controls were included in the study. CRI-I, CRI-II, AIP and AC parameters showed an increase after treatment (p<0.001 for all parameters). There was no significant difference between patients and controls in terms of CRI-I and CRI-II and AC (p=0.129, p=0.573, p=0.129 respectively). Although mean AIP levels of patients was significantly lower than control group (p=0.031), the significance disappeared when we compared the patients and controls according to being in low, medium, and high risk groups (χ2=0.826, p=0.662). CONCLUSIONS: Even in short term of treatment, antipsychotics have an important role in developing dyslipidemia and increasing cardiovascular risk. Manic state may have positive or at least no additional influences on atherogenic risk.

Serum soluble urokinase-type plasminogen activator receptor levels in male patients with acute exacerbation of schizophrenia.

Inflammatory abnormalities have been shown in the pathogenesis of schizophrenia. Soluble urokinase-type plasminogen activator receptor (suPAR) is a protein that is measurable in the circulating blood and reflects the inflammation in the body. We aimed to investigate serum suPAR levels in patients with schizophrenia who were in acute state and to compare with healthy controls. Forty five patients and 43 healthy controls were included in the study. We found no significant difference in suPAR levels between patients and controls, suggesting that suPAR as an inflammatory marker does not have a role in the inflammatory process of acute schizophrenia.

Neutrophil-lymphocyte and platelet-lymphocyte ratios as inflammation markers for bipolar disorder.

In the present study we investigated the involvement of inflammatory cells and their ratios as inflammation markers in Bipolar Disorder. We have enrolled 61 manic, 55 euthymic patients and 54 control subjects to the study. Neutrophil-lymphocyte and platelet-lymphocyte ratios were found significantly higher in both manic and euthymic patients compared to control group. These findings suggest that the inflammatory cells have a role in the pathophysiology of bipolar disorder manic and even in euthymic state.

Plasma BDNFs level initially and post treatment in acute mania: comparison between ECT and atypical antipsychotic treatment and healthy controls.

BACKGROUND: Inconsistent findings concerning brain-derived neurotrophic factor (BDNF) levels across different episodes in bipolar disorder have been reported, which is also in line with the treatment effects on BDNF levels in acute mania. We aimed to compare plasma BDNF level alterations after pure antipsychotic drug or ECT plus antipsychotic drug treatment in acute mania. METHODS: Sixty-eight patients with mania were divided into two treatment arms: the antipsychotic treatment arm (AP) and electroconvulsive therapy (ECT)+AP arm. In addition, 30 healthy controls were included in the study. RESULTS: There was no significant statistical difference according to mean age, education level, marital and working status between patients and healthy controls. The initial serum BDNF level in patients with acute mania was significantly lower than healthy controls. The initial BDNF level between the ECT arm and AP arm was not significant. The BDNF level decreased significantly after reaching remission in patients with acute mania. The change in BDNF level in the AP arm was not significant while in the ECT arm it was significant after treatment. CONCLUSIONS: In this study, for the first time we revealed a significant decrease in BDNF levels after ECT sessions in acute manic patients. Besides clinical remission after treatment in acute mania, the decrement in BDNF levels does not seem to be related to clinical response. Thus cumulative effects of mood episodes for the ongoing decrease in BDNF levels might be borne in mind despite the achievement of remission and/or more time being required for an increase in BDNF levels after treatment.

Level of plasma thioredoxin in male patients with manic episode at initial and post-electroconvulsive or antipsychotic treatment.

AIM: Oxidative stress is defined as exposure to excessive oxidants and/or decrease in antioxidant capacity. Several studies have shown the effects of free radicals and antioxidant defense systems in bipolar disorder. We aimed to investigate the role of thioredoxin (TRX), which is a novel oxidative stress marker in patients with bipolar disorder. METHODS: Sixty-eight hospitalized bipolar patients who were in manic episode were included in the study. As a control group, 30 healthy people were elected. Two groups were formed. The first group consisted of patients who were undergoing electroconvulsive treatment + antipsychotic treatment (haloperidol+quetiapine) and members of the other group were taking only antipsychotic treatment. Plasma thioredoxin levels were measured before and after treatment. RESULTS: Pretreatment plasma TRX levels of patients were significantly lower than the controls (P < 0.05). Comparing pre- and post-treatment plasma TRX levels of all patients, post-treatment plasma TRX levels were significantly lower than the pre-treatment plasma TRX levels (P < 0.05). When we compared TRX levels between the electroconvulsive treatment + antipsychotic treatment group and the antipsychotic treatment group (P > 0.05) and within groups (P > 0.05) we did not find any statistically significant difference. CONCLUSION: Oxidative balance is impaired in bipolar disorder manic episode in favor of the oxidants. Decreased plasma TRX levels in the manic episode probably mean that antioxidant capacity is decreased in the bipolar disorder patients in the manic episode. Further studies in euthymic and depressive states are also needed to gain more insight into the role of TRX in bipolar disorder.

Initial and post-treatment total oxidant-antioxidant status and oxidative stress index in male patients with manic episode.

We investigated serum total oxidative and anti-oxidative status in manic patients. Group1 was formed as ECT+antipsychotic, group2 was antipsychotic and healthy volunteers as group3. The anti-oxidative status was significantly lower in group1 than group3. No significant change was found between pre and post-treatment oxidative and anti-oxidative status, whereas significantly increased oxidative stress index has been found in group2. Total anti-oxidative status in manic states seems to be inadequate which remains to be maintained after the treatment.

The nesfatin 1 level in male patients with manic episode and alterations of nesfatin 1 level after antipsychotic and electroconvulsive treatment.

BACKGROUND: Nesfatin 1 is a newly identified peptide structured satiety hormone that is claimed to be responsible for the provision of appetite and metabolic regulation in hypothalamus. The change in appetite and energy is a well-known clinical feature of affective disorders and within treatment. We aimed to investigate serum nesfatin 1 level in patients with bipolar disorder who were in manic episode and the influences of treatment modalities on nesfatin 1 level. METHODS: Sixty eight patients were elected and were divided into two groups as: antipsychotic treatment (haloperidol 10-30 mg/daily+quetiapine 100-900 mg/daily) arm and ECT+antipsychotic treatment arm. And 30 healthy controls were included in the study. RESULTS: There was no significant difference according to mean age between patients and controls. Initial nesfatin 1 levels in patients and in both subgroups of patients were statistically lower than in healthy control group. The initial level of nesfatin 1 between ECT+antipsychotic and pure antipsychotic patient groups was not statistically significant. We found a trend of increment in nesfatin 1 level after treatment in both patient groups. CONCLUSIONS: This study is the first that revealed significantly lower nesfatin 1 level in manic episode than healthy controls. ECT+antipsychotic and antipsychotic treatments have no significant effects on nesfatin 1 level after manic episode treatment. These findings should be interpreted cautiously because of small sample size and being drug free only for one week.

A case report of priapism caused by ziprasidon.

Priapism is defined as having prolonged (more than 6 h), and usually painful penile erection that occurs without a sexual desire or arousal. Only a very few priapism cases caused by ziprasidone are reported in the literature. In this case report we aimed to present a prolonged penile erection due to use of ziprasidone.