Rethinking Palliative Care in Psychiatry.

This Viewpoint describes specific issues related to severe mental illnesses for palliative care.

Rheumatology and palliative care: needs and opportunities.

Palliative care (PC) has expanded to medical conditions beyond its conventional scope of terminal malignancy and end-stage organ failure. This editorial showed our opinion in care model for the integration of PC into rheumatology and the growing needs of both rheumatology and PC services in view of increasing comorbidities and novel therapies. We anticipate an escalating demand for PC in this special group of patients who have concomitant long-standing systemic rheumatic diseases and age-related comorbidities. In addition, patients with advanced malignancy who develop rheumatological problems and require PC is also an emerging area of service need.

Cirrhosis associated with pyridoxal 5'-phosphate treatment of pyridoxamine 5'-phosphate oxidase deficiency.

We report the case of an 8-year-old boy with pyridoxamine 5'-phosphate oxidase (PNPO) deficiency. He developed seizures at 24 h of age that were refractory to standard anticonvulsant therapy and a trial of pyridoxine but responded to pyridoxal phosphate (PLP) at 28 days of life. Genetic testing identified compound heterozygous mutations in the PNPO gene. Management of encephalopathic episodes required escalation of PLP dose to 100 mg/kg/day by 2 years of age. Routine blood tests at this time showed significantly deranged liver function tests (LFTs). A wedge liver biopsy showed early cirrhosis with marked elevation of pyridoxal and pyridoxic acid levels in the liver sample. Despite extensive investigation, no cause other than PLP therapy could be identified for the cirrhosis. The PLP dose was weaned to 50 mg/kg/day before episodes of encephalopathy recurred. Concurrent with the reduction of his PLP dose, LFTs showed improvement. However, at 8 years of age, there is persistent evidence of hepatic fibrosis and early portal hypertension. We hypothesise that hepatic toxicity due to PLP or its degradation products is the cause of cirrhosis in this boy. Until further evidence becomes available, we would suggest that people with PNPO deficiency are treated with the minimum dose of PLP required to prevent episodes of encephalopathy.

A prospective study of acute movement disorders in children.

AIM: The purpose of this study was to report a prospective cohort of children with acute-onset movement disorders. METHOD: We report on 52 individuals (31 females, 21 males; mean age 6y 5mo, range 2mo-15y) with acute-onset movement disorders managed at a busy tertiary paediatric referral hospital over a 40-month period. RESULTS: In descending order of frequency, the movement disorders reported were chorea, dystonia, tremor, myoclonus, and parkinsonism. It was possible to divide the participants into three groups: (1) those with inflammatory or autoimmune disorders (n=22), (2) those with non-inflammatory disorders (n=18), and (3) those with psychogenic disorders (n=12). The inflammatory or autoimmune aetiologies included N-methyl-D-aspartate receptor encephalitis (n=5), opsoclonus-myoclonus syndrome (n=4), Sydenham chorea (n=3), systemic lupus erythematosus (n=3), acute necrotizing encephalopathy (n=3), and other types of encephalitis (n=4). Other important non-inflammatory movement disorder aetiologies included drug-induced movement disorder (n=6), post-pump chorea (n=5), metabolic (n=3) and vascular (n=2) disease. The participants with psychogenic movement disorders (n=12) were all over 10 years of age and were more likely to be female. Tremor and myoclonus were significantly over-represented in the psychogenic movement disorder subgroup. The outcomes of the total cohort were variable, and included full recovery, severe morbidity, and death. INTERPRETATION: Acute-onset movement disorders in children are important and may be treatable. Management should focus upon identifying the cause and treating the underlying disease process, as symptomatic treatment of the abnormal movements is variably effective.

A rapid cation-exchange HPLC method for detection and quantification of pyridinium oximes in plasma and tissue.

A rapid and sensitive assay for pyridinium oximes in plasma and tissue was developed. The method was suitable for the analysis of mono- and di-pyridinium oximes and utilizes ultrafiltration followed by cation-exchange high-performance liquid chromatography with UV detection. The assay was originally developed for the measurement of the oxime MMB-4 in plasma for which the lower limit of detection was 0.0005 pg and the limit of quantitation was 0.001 to 2.5 microg. The assay required as little as 50 microL of whole blood or 30 pL of tissue homogenate, and it was used for a pharmacokinetic study from a single intramuscular injection of MMB-4 (dichloride or dimethylsulfonate salt) in the guinea pig. Both salts were found to have similar pharmacokinetic properties in the plasma with a T1/2 of about 34 to 42 min and the area-under-the-curve values increased dose dependently. MMB-4 tissue concentrations were much lower than the plasma. The tissue levels peaked at 5-20 min depending on the tissue. A rank of concentration was diaphragm > heart > thigh muscle.

A study of health risk behaviour and social factors of women between ages 25-59 years in Trinidad

The three main objectives of this study were to (a)describe and compare health status of urban and rural women in Trinidad with respect to economic, demographic and educational factors, (b) evaluate women's knowledge of and attitude towards self-breast examination and cervical screening and (d) determine their utilization pattern of health care services. A total of 1,450 women were interviewed for the study. The overall sample size, n, was calculated to be approximately 1,450 households, given a 5 percent non-response rate. Probability sampling and a nationally representative sample of the population was used. The statistical techniques used to assemble, describe and infer were exploratory analysis, partial correlation analysis and multi-step wise regression. The study identified several factors that influenced a woman's decision to have a Pap Smear Test: education level, age, religion, ethnicity, marital status, employment and income status. Those with higher levels of education had a greater probability of having a Pap test. Of the women aged 40-44 years, 48.1 percent were more knowledgeable about the purpose of the Pap test. The influence of religion was apparent with the Christian community exhibiting a higher percentage of screening compared to the Hindu and Muslim women. The results of Ethnicity found that (10.6 percent) of women of African origin had abnormal test results compared to women of East Indian origin, (4.4 percent). Married women had lower levels or cervical cancer, compared to unmarried women. The percentage of women feeling confident to perform breast self-examinations was lowest among women with low education level (36.4 percent) compared to women with tertiary level education, (68.0 percent). Cervical cancer is more common in women of low socioeconomic status and educational levels. Our study shows these factors influence their inadequate utilization of Pap smear services. Knowledge of the purpose of a Pap smear also relates to their socioeconomic status. It indicates that dissemination of information pertaining to Pap test, cervical cancer and availability of healthcare must be tailored to women represented in these groups (AU)