Medication misuse and abuse: duties and responsibilities of dispensing pharmacists.

Misuse of medications can have major consequences for the consumer or patient's health. In the case of a drug delivered only on medical prescription, the misuse usually results from an error or negligence on the part of the prescribing doctor and/or the pharmacist dispensing the medication. But whereas, under French Law, doctors are regularly prosecuted for their irresponsibility, pharmacists frequently avoid any legal charges. This is even more surprising in view of the fact that French Legislation controls the practice of pharmacy very strictly. The authors discuss four cases that illustrate this issue and present a study of comparative pharmaceutical law requirements.

New GABAA receptor alpha5 subunit gene polymorphism that may confound genotyping.

We report the discovery of a new GABAA receptor alpha5 subunit gene polymorphism close to the polymorphism described by Glatt et al. (GT)5GCGTGC(GT)21. This new polymorphism is of great importance, because it means that non-denaturing acrylamide gels used to separate the different alleles of the polymorphism described by Glatt et al. cannot distinguish an allele with the sequence: (GT)4GCGTGC(GT)n from another allele with the sequence: (GT)4(GCGT)4GC(GT)(n-6). These gel fragments are separated by size, which would be the same in these two cases. An alternative would be to use an analysis method that can detect base changes, for instance, single strand conformation polymorphism (SSCP) or denaturing gradient gel electrophoresis (DGGE).

Dimensions of suicidal behavior according to patient reports.

Five factor analyses with limitations explored the Suicidal Intent Scale (SIS) subscales reflecting suicidal behavior dimensions. This larger sample study conducts an exploratory factor analysis of the SIS. Two large samples of suicide attempters (N= 435 and N= 252) from a general hospital were studied. The validity of SIS subscales obtained from the factor analysis was investigated by examining the association between the subscales and clinical variables. There were two factors: expected lethality and planning. In both samples, male gender and depression tended to be associated with higher scores in both subscales (small to medium effect sizes). Hospitalization was associated with higher scores in both SIS subscales (medium to large effects) suggesting that these subscales were reasonably good predictors of suicide attempt severity. Clinicians assessing patient reports to establish the severity of suicide attempts need to ask questions regarding both dimensions: expected lethality and planning.

[Familiar history of suicidal behavior]. / Historia familiar de conducta suicida.

Suicide is such a serious public health problem that it has been proposed as an indicator of mental health of a society. Self-harm, a behavior related with suicide, is also a public health problem with a prevalence 8 to 15 times higher than suicide. Suicide behavior is the result of different social, cultural, biological and psychopathological factors and affects all the cultures. This clinical case of 4 brothers from a family of 8 siblings seen repeatedly due to suicide attempts make it possible to discuss these factors. The family and social report describes a low economical and cultural level. The family climate is marked by aggressive environment and inappropriate care of the children. Different members of the siblings initiated drug consumption as a teenager. It is interesting to point out the high frequency of suicide attempts in this family and the health resources used as well as the deterioration in the quality of life associated. The elevated weight of the fa m i ly factors in the development of the suicide behavioris observed and offers the opportunity of questioning if whether it is the environmental factors, genetic vulnerability to mental disorder or specific predisposition to suicidal behavior that is transmitted in the family.

[Lumbar disc disease in adolescents]. / Hernia discal lumbar en adolescentes.

INTRODUCTION: Intervertebral disc herniation is a very common neurosurgical pathology. Most commonly disc disease occurs in adults and series published in children are only few and each reports only few cases. A genetic factor has been considered but in none of our patients there was a family history of disc disease. PATIENTS AND METHODS: We report ten patients with disc herniations in adolescents occurring among 1920 patients operated of herniated discs between 1988 and 1998. These herniations in adolescents were all related to some sport activities, and they occurred in the age range of 12 to 16 years. Symptoms were back pain and lower extremities pains of roots L5 or S1. All were studied with magnetic resonance imaging and in all patients the herniated disc was either in L4 L5 or L5 S1 intervertebral spaces. All disc were subligamental and 81.5% were posterolateral in position. Pathological studies of the herniated discs showed elastic consistency with high water content without degenerative changes. RESULTS: After microscopic removal of the herniated discs pain disappeared and remained so in the follow up. It was not necessary to reoperate in any of these patients and the postoperative follow up was between 2 and 5 years. CONCLUSIONS: Herniated disc disease is very infrequent in adolescents and all recovered completely after surgery, and the localization is posterolateral and subligamental.

Hernia discal lumbar en adolescentes / Lumbar disc disease in adolescents

Introducción. Las hernias discales son una patología habitual dentro de la Neurocirugía, pero la presentación suele producirse en la edad adulta y las series publicadas en niños son pocas y con un número de casos pequeño. Se ha invocado un factor genético, pero en ninguno de nuestros casos existía antecedente familiar de hernia de disco. Pacientes y métodos. Se presentan 10 hernias discales lumbares (HDL) en adolescentes en una serie de 1.920 HDL, que abarca desde 1988 hasta 1998. Todos los casos de la serie se presentaron asociados a la realización de algún tipo de deporte. Las edades estaban comprendidas entre los 12 y los 16 años. La clínica fue un cuadro de dolor lumbar con irradiación por el territorio radicular asociado (L5 o S1). Todos los casos se estudiaron con resonancia magnética y su localización fue, en el 100 por ciento, entre L4-L5 y L5-S1; todas eran hernias subligamentosas y el 81,5 por ciento aparecieron en posición posterolateral. La anatomía patológica demostró una consistencia elástica y alto contenido en agua, sin fenómenos degenerativos. Resultados. En todos los casos desaparecía el cuadro doloroso y se hacían asintomáticas tras la realización de extirpación por el procedimiento de microdisectomía. No se precisó reintervención en ningún caso, y el control postoperatorio fue de entre 2 y 5 años. Conclusiones. La HDL del adolescente es una patología poco frecuente y en todos los casos los resultados fueron buenos después de la intervención quirúrgica. La localización generalmente es subligamentosa posterolateral (AU)

Introduction. Intervertebral disc herniation is a very common neurosurgical pathology. Most commonly disc disease occurs in adults and series published in children are only few and each reports only few cases. A genetic factor has been considered but in none of our patients there was a family history of disc disease. Patients and methods. We report ten patients with disc herniations in adolescents occurring among 1920 patients operated of herniated discs between 1988 and 1998. These herniations in adolescents were all related to some sport activities, and they occurred in the age range of 12 to 16 years. Symptoms were back pain and lower extremities pains of roots L5 or S1. All were studied with magnetic resonance imaging and in all patients the herniated disc was either in L4-L5 or L5-S1 intervertebral spaces. All disc were subligamental and 81.5% were posterolateral in position. Pathological studies of the herniated discs showed elastic consistency with high water content without degenerative changes. Results. After microscopic removal of the herniated discs pain disappeared and remained so in the follow up. It was not necessary to reoperate in any of these patients and the postoperative follow up was between 2 and 5 years. Conclusions. Herniated disc disease is very infrequent in adolescents and all recovered completely after surgery, and the localization is posterolateral and subligamental (AU)

Subdural empyema with extension to vertebral canal secondary to salmonellosis in a patient with systemic lupus erythematosus.

CASE REPORT: A case of supratentorial subdural empyema extending to the superior subdural cervical space in a 14-year-old patient with systemic lupus erythematosus is presented. The presumed etiology of the empyema was an intestinal nontyphoidal salmonella infection. DISCUSSION: We review the neurological and neurosurgical complications in systemic lupus erythematosus.

[Sociodemographic features of suicide attempts]. / Aspectos sociodemográficos de los intentos de suicidio.

Suicide accounts for about 10% of deaths among psychiatric patients, and life-threatening attempts are much more common than fatalities. Despite progress in defining risk rates and predictive factors, knowledge on which to base sound clinical and public policies regarding suicide prevention and treatment remains remarkably limited. Social risk factors and psychiatry diagnoses are the main arguments to management the suicidal behaviour in emergency room. Female gender is associate with suicide attempts while male gander is associate with completed suicide. Risk of suicide is increased in young and elderly people. Age is a confounding factor in the relationship among suicide and widow, income and professional status. Emigration and anomie are related with suicide. Social factor, as a marker of suicidal behaviour, are a promising research question.

Aspectos sociodemográficos de los intentos de suicidio / Sociodemographic features of suicide attempts

La conducta suicida es un importante problema de salud pública en el que los factores sociodemográficos desempeñan un papel importante tanto en su génesis como en las intervenciones preventivas y terapéuticas sobre estas conductas. Los factores sociodemográficos, junto al diagnóstico psiquiátrico, han sido los elementos sobre los que se ha basado la decisión terapéutica en el manejo del intento de suicidio. Así el género femenino se ha ligado a este tipo de conducta mientras el género masculino se ha relacionado más con el suicidio consumado. Se ha considerado que los jóvenes y los ancianos tenían más riesgo de conductas suicidas severas. La edad se entremezcla con el estado civil potenciándose el riesgo en el caso de solteros y viudos. En esta línea los jóvenes homosexuales y bisexuales también tienen un mayor riesgo de suicidio. La emigración y el desarraigo que conlleva es un marcador de riesgo a tener en cuenta. Se ha comprobado que los factores económicos (ingresos y situación laboral) tienen un peso modesto en el riesgo de suicidio. La escasez de trabajos que valoren las interacciones de varios de estos factores, constituyendo una línea de investigación, aún muy prometedora, en este campo (AU)

A prospective study of the paradoxical relationship between impulsivity and lethality of suicide attempts.

BACKGROUND: Biological studies suggest that lower serotonergic activity is associated with both greater suicide lethality and impulsive personality traits. These results may lead to the conclusion that impulsivity in the attempt should be associated with greater lethality. However, Klerman's review of epidemiologic suicide studies suggests an inverse relationship between impulsivity and lethality. This seemingly paradoxical relationship between impulsivity and lethality has not been explored in large representative clinical samples of suicide attempts. METHOD: During 1996 to 1998, 478 individuals who attempted suicide were studied in a general hospital in Madrid, Spain. Impulsivity was measured as described in the literature by combining 2 items of Beck's Suicidal Intent Scale (active preparation for attempt and degree of premeditation). Lethality of the attempt was assigned 1 of 4 levels according to the need for medical and/or psychiatric treatment. RESULTS: More than half of the attempts were impulsive (55%; 95% confidence interval [CI], 51% to 59%), approximately one fourth of the attempts had an intermediate level of impulsivity (28%; 95% CI, 24% to 32%), and approximately one sixth of the attempts were not impulsive (17%, 95% CI, 13% to 21%). There was an inverse association between the impulsivity and lethality of the suicide attempt (chi2 = 62.639, df = 6, p < .0001). The most impulsive attempts tended to result in less morbidity, while the less impulsive attempts tended to be more lethal. CONCLUSION: If the inverse relationship between impulsivity and lethality is replicated in other large and representative samples, new studies will be needed to clarify the complex interactions between the clinical dimensions (lethality, impulsivity as a state, and impulsivity as a personality trait) and the biological correlates (particularly serotonergic function) of suicidal behavior.

Assessment of reliability in the clinical evaluation of depressive symptoms among multiple investigators in a multicenter clinical trial.

The objective of this work was to determine the severity of depressive symptoms when multiple clinical examiners evaluate a single subject, as preparatory to their participation as evaluators in a clinical trial. Using the 17-item Hamilton Depression Rating Scale (HDRS), 37 psychiatrists independently assessed the videotape of a patient with symptoms of depression. A new measure for the detection of multiple examiners not in consensus (DOMENIC) was used to identify scale items with low reliability and raters with low inter-rater reliability, from among the remaining raters. Overall inter-rater agreement on the full HDRS was 'excellent' (97%). All raters but one showed adequate agreement both on individual items and on total scores. Two of the 17 HDRS symptomatology items had unacceptable levels of inter-rater scoring variability (<70% agreement). The use of DOMENIC allows for the detection of items of low inter-rater reliability and identification of raters that deviate from the group's ratings prior to the beginning of a clinical trial.

The relationship between menstrual cycle phases and suicide attempts.

OBJECTIVE: The validity of prior studies on the menstrual cycle and suicide attempts assumes that suicidal women accurately describe their cycles. The three objectives of this study were 1) to explore whether prior inconsistencies are due to the effects of sample selection and method of assessment of the menstrual cycle, 2) to assess the relationship between the menstrual cycle phase and suicide attempts, and 3) to establish the role of sexual hormones in suicide attempts. METHODS: The original sample included 134 women who came to the emergency room of a general hospital after a suicide attempt. One hundred eight female blood donors were recruited as control subjects. The menstrual cycle was divided into follicular, midcycle, and luteal phases using two clinical methods and serum hormonal assessment. Dividing the follicular phase into menstrual and nonmenstrual phases was also considered. RESULTS: Two of 11 previously used sampling methods produced a sample size similar to that of the hormonal assessment. kappa values between the two clinical and the endocrinological methods were low (0.40-0.50). The number of suicide attempts during the follicular phase (particularly during the menstrual phase) was significantly higher than expected. CONCLUSIONS: Despite the inability to control for other variables and limitations, the results of this study suggest that sample selection could introduce biases and that studies relating psychiatric symptomatology and menstrual cycle phases need to use hormonal determinations. New studies are needed to verify that suicide attempts are more frequent during the follicular phase (particularly during the menstrual phase).

[Attempted suicide and previous contact with health system]. / Demanda de asistencia previa al intento de suicidio.

INTRODUCTION: Suicide behavior is an important health problem. Several works found have reported that the majority of completed suicides visited to the general practitioner in previous days. METHOD: 219 suicide attempts attended in a General Hospital were asked about their previous contact with health system. RESULTS: The third part of the patients have visited the general practitioner in the previous month. 60% of the patients with personal antecedents of psychiatric diseases have visited to mental services in the previous month. CONCLUSIONS: It is necessary to find risk suicide markers that allow identifying these patients in primary attention. The increment of the consultation periodicity is proposed as efficient risk suicide marker.

[Analytical thyroid disturbances in psychiatric inpatients]. / Un estudio de la función tiroidea en pacientes psiquiátricos ingresados.

BACKGROUND: There is not an agreement about the screening for thyroid disease in psychiatric inpatients. METHODS, The thyroid status of 172 psychiatric inpatients was assessed at the beginning of their hospitalization. A logistic regression was performed lo find the factors related with abnormal levels of thyroid hormones. RESULTS: As many as 30.8% of the inpatients presented levels of thyroid hormones and 5.2% have thyroid disease. The model chi2 was excellent (chi2= 20.89; gl= 4; p< 0.0001), the sensitivity was de 0.38 and the specificity was 0.83. Five variables fulfilled the criteria to be entered and not removed from the model: sex, schizophrenia, previous mental disorder, treatment with lithium, current infectious illness. CONCLUSIONS: A screening for thyroid disorder in psychiatric inpatients, at the beginning of their hospitalization, is recommended in female patients, schizophrenics and patients in treatment with lithium.

[Predictors of behavioural disorders and consultation-liaison psychiatry in patients with HIV disorders]. / Predictores de trastornos de conducta e interconsulta psiquiátrica en hospitalizados por trastornos-VIH.

OBJECTIVE: The aim was to identify the features of patients admitted into an Infectious Disease Unit in a Hospital due to pathology related to HIV and/or addiction that originate the demand for consultation liaison psychiatry. METHOD: During the first six months of 1997, 232 admissions into the Infectious Disease Unit at Ramón y Cajal Hospital (191 patients) were systematically evaluated by the nursery staff. A specific questionnaire was designed for this interview. After having performed univariants analysis, a logistic regression was used to identify the most relevant variables in the claim for consultation liaison. RESULTS: The claim for consultation liaison was associated to: consume in the unit OR (yes/no)= 7.9, confusional syndrome OR (yes/no)= 5.6, social worker consultation liaison OR (yes/no)= 2.1. use of benzodiazepines OR (yes/no)= 2.4. No medical treatment respect to bad accomplishment OR= 3.6. Only taking into account the known features after the first examination: use of benzodiazepines OR (yes/no)= 2.1, use of cocaine OR (yes/no)= 1.8, recognized income (yes/no)= 2.2, no medical treatment due to bad accomplishment OR= 2.1. CONCLUSIONS: In our environment the demand for consultation liaison psychiatry is related to behavioural problems due to the use of substances and marginality. The variables which predict the demand and may be identified at the time of admission are: the use of benzodiazepines, cocaine, the lack of a recognized income and the absence of medical treatment for the HIV infection. Recognizing these features will allow us to identify patients who are going to have behavioural problems and demand psychiatric assistance.

[Dysembrioplastic neuroepithelial tumors]. / Tumores neuroepiteliales disembrioplásicos.

INTRODUCTION: The dysembryoplastic neuroepithelial tumours, first defined by Dumas-Duport in 1988, are characterized histologically by being found in the cerebral cortex and having a histological pattern of multinodular architecture, foci of cortical dysplasia and a specific glioneuronal element. The clinical condition is characterized by seizures with a long evolution. These seizures are usually simple or complex partial seizures, but occasionally become generalized tonic-clonic seizures. Radiological findings on CAT or MR are cystic images localized to the cortex, with a solid component and do not cause displacement. The surgical operation required involves excision of the lesion or lesionectomy. This may be done so as to include 1 cm of the periphery of the lesion. The evolution is excellent and in most cases the seizures disappear. CLINICAL CASES: We present 4 cases of a series of 470 patients with tumours of the nervous system, operated on over the past 10 years in the Hospital del Niño Jesús. The evolution of these 4 cases has been from 1 to 5 years. In all 4 cases lesionectomy was carried out, and the evolution has been excellent (grade I of Engel's classification). CONCLUSIONS: 1. Dysembryoplastic neuroepithelial tumours are solid and cystic, situated in the cerebral cortex, with foci of cortical dysplasia. They are characterized by having a specific glioneuronal element. 2. Clinically they are characterized by crises with a long evolution. 3. The surgical operation involves lesionectomy or excision of the lesion. The evolution is excellent.

[Limitations of the diagnosis of bipolar disorder]. / Los límites del diagnóstico del trastorno bipolar.

INTRODUCTION: It has been studied the possible confusion in the diagnosis of bipolar disorder when there are no clear mania symptoms and other psychiatric disorders, due to his clinic similarity. The diagnosis received from a group of patients admitted in a Psychiatric Unit of a General Hospital by manic episode were studied. METHODS AND MATERIAL: 84 admitted patients have been followed up along an average of 32 months. By means logistic regression, there were found the factors that explained the change in the diagnosis along the evolution. RESULTS: 87% of the patients after the follow up kept the diagnosis of bipolar disorder. However, 63.1% had received other diagnosis. Two factors predicted to receive other diagnosis: depressive clinic and not having stable couple. CONCLUSION: Bipolar disorder presents a proper stability once diagnosis have been made. It may be confused with psychotic sight, unipolar depression and B cluster personality disorders. It is checked that patients which start with manic psychosis phases are the ones that present biggest diagnosis stability.

[Assessment of clinical assessment reliability among researchers of a multicenter clinical trial]. / Valoración de la fiabilidad de la evaluación clínica entre los investigadores de un ensayo clínico multicéntrico.

INTRODUCTION: Interater agreement is a main aspect in the planning and conducting a clinical trial. The objective of this study is to show the application of assessing levels of interexaminer's agreement when multiple ratings are made on a single subject as an efficient method of evaluating the interater's reliability in planning a multicenter clinical trial. METHOD: 39 psychiatrist assessed videotape of a patient with depression. The use of any reliability statistics is failed in the analysis of multiple independent ratings of a single subject since we used the methodology proposed by Cichetti et al. This method is able to identify raters whose ratings differ significantly from the average ratings and is sensitive for different levels of agreement. RESULTS: Interarter agreement was between good and excellent. The raters show an adequate agreement in total and items scores. CONCLUSION: The design proposed permits evaluate the interater agreement in an efficient way (only in one session).