[Valproic acid toxicity due to misinterpretation of plasma levels: increase in unbound fraction caused by hypoalbuminaemia and renal dysfunction]. / Valproïnezuurintoxicatie door misinterpretatie van plasmaspiegel.

BACKGROUND: Valproic acid is one of the most widely prescribed drugs for the treatment of epilepsy and bipolar disorder. As only the unbound fraction of a medicinal product is pharmacologically active, in some strong protein-bound psychotropic drugs such as valproic acid and phenytoin, a rise in this fraction can lead to severe toxicity. CASE DESCRIPTION: A 65-year-old male with a type 1 bipolar disorder developed a number of neurological symptoms including sluggishness, muscle weakness, difficulty in walking and disorders of micturition after his mood stabiliser was changed to valproic acid. Recognition of drug toxicity was delayed as his total plasma valproic acid levels were within the therapeutic range. Later it became apparent that the patient had toxic unbound valproic acid levels due to hypoalbuminaemia and impaired renal function. CONCLUSION: Clinicians should always consider drug toxicity in patients who show neurological symptoms and use highly protein-bound psychotropic drugs, even if the total plasma concentration of the drug is in the therapeutic range.

[A homeless, uninsured illegal alien suffering from psychosis and multiple fractures: providing efficient care to such patients]. / Een dakloze, onverzekerde illegaal met multipele fracturen en een psychose: Hoe kun je zo'n patiënt doelmatige zorg verlenen?

We present the case of a 37-year-old psychotic, homeless man from Albania, who sustained multiple fractures after jumping from a third-floor window. The patient was uninsured and did not consent to transfer to a hospital in Albania because of paranoid delusions. Eventually he was hospitalised for nearly 30 weeks in hospital and a nursing home. Various factors of this complex case are considered, such as the co-morbidity of somatic and psychiatric symptoms, the absence of family support and the financial regulations that apply to uninsured patients. Doctors who are presented with similar complex cases are advised to organise frequent multidisciplinary evaluations with all health care workers involved. We encourage searching for creative interventions which serve both the best interests of the individual patient, and - where possible - also minimize the total cost of health care to society.

The association of depressive symptoms with survival in a Dutch cohort of patients with end-stage renal disease.

AIM: To evaluate the prevalence and the influence on survival of depressive symptoms in a European cohort of end-stage renal disease (ESRD) patients on renal replacement therapy (RRT). METHODS: In a prospective fashion, symptoms of depression were evaluated in ESRD patients on RRT using the depression subscore of the Hospital Anxiety and Depression Scale (HADS). Fatal and non-fatal clinical events were determined during a 1-year follow-up. RESULTS: Of 101 patients with ESRD, 42% showed manifest depressive symptoms, defined as a HADS-D score > or =7. No association was found between depressive symptoms and severity of somatic disease. During follow-up, all-cause mortality was significantly higher in patients with depressive symptoms above threshold (n = 42, mortality: 26%) compared to patients with depressive symptoms below threshold (n = 59, mortality 8%), (crude HR 3.3, CI 1.2-9.6, P = 0.02). The excess in mortality was mainly caused by a higher incidence of septicaemia (0 versus 12%, P = 0.01). After adjustment for clinical parameters, this association between depressive symptoms and mortality became even stronger. There was no significant difference observed in the incidence of cardiovascular events. CONCLUSIONS: Patients with ESRD treated with dialysis show a high level of depressive symptoms that is independently associated with poor survival. Future research should address appropriate therapeutic regimens.