1038
RESPONSE ON ELTOPRAZINE (NATURALISTIC RATING
PROCEDURES)
*DSM-III-R
psychotropic drugs (table). Besides moderate to severe insomnia in patients 1,3,4, and 9, no side-effects were reported. These results support the hypothesis that serotonin is involved in the pathogenesis of self-injury. The effects of eltoprazine, including those on social behaviour, seemed to diminish after 6 weeks in most of the patients. We do not know why. Mechanisms such as alterations in receptor sensitivity, changes in phannacokinetics, or overriding environmental factors might be involved. Vincent van Gogh Institute for Psychiatry, PO Box 5, 5800 AA Venray, Netherlands
St
Augustinus Institute for Mental Retardation,
Gennep
WILLEM M. A. VERHOEVEN SIEGFRIED TUINIER No A. S. SIJBEN YVONNE W. H. M. VAN DEN BERG E. P. P. M. DE WITTE-VAN DER SCHOOT
Section of Pathophysiology of Behaviour, Erasmus University,
University Hospital, Utrecht
Maudsley Hospital, London SE5 8AZ, UK
PHILIP A. LUCAS
Department of Nephrology, Institute of Urology and Nephrology, Middlesex Hospital, London
BRIAN R. LEAKER GUY H. NEILD
1 Chin
Rotterdam;
Department of Child Neurology,
subjects had paramedical backgrounds. At least 5 had taken analgesia stronger than dihydrocodeine. Preliminary results suggest that 9 of the 15 had had at least one previous episode of severe depression. Of these, only 1 had a definite depressive illness at the time of interview and 2 others were equivocal. In 7 subjects, onset had occurred after a psychologically significant event, typically a loss, that was unrelated to their medical condition. Our most striking finding concerned intra-familial relationships. A history of a childhood obligation to take care of one or both chronically sick parents was given clearly by 12 and suggested by at least 2 others. Although overt depression/anxiety is not usually a feature of LPH, we suggest that the syndrome has much in common with somatoform pain disorder, about which the Diagnostic and Statistical Manual of Mental Disorders’ states "the predominant disturbance is at least six months’ preoccupation with pain ... [and] when there is related organic pathology, the pain or resulting social or occupational impairment is grossly in excess of what would be expected from the physical fmdings". The aetiology and pathogenesis of somatoform pain disorder is poorly understood, but adults who somatise have consistently proved to have increased childhood experience of illness in close relatives, especially parents5 Recurrence of pain in the autotransplanted kidney has been reported.6 Whatever the part played by regeneration of autonomic nerve fibres’ in the mechanism of this pain, our study suggests an important role for powerful underlying emotional dynamics. We believe that appropriate investigations, explanation, and long-term supportive care are the most important aspects of management, and are perhaps most satisfactorily delivered by an experienced renal physician together with a multidisciplinary team, including psychiatric colleagues.
LOLKE PEPPLINKHUIZEN ONNO VAN NIEU WENHUI ZEN
Praag HM. Serotonergic dysfunction and aggression control: serotonin and (auto-)aggressive behavior. Psychol Med 1991; 21: 15-19. 2. Markowitz PI. Fluoxetine treatment of self-injurious behavior in mentally retarded patients. J Clin Psychopharmacol 1990; 10: 299-300. 3. Primeau F, Fontaine R. Obsessive disorder with self-mutilation- a subgroup responsive to pharmacotherapy. Can J Pychiatry 1987; 32: 699-700. 4. Rasmussen DL, Olivier B, Raghoebar M, Mos J. Possible clinical applications of serenics and some implications of their preclinical profile for their clinical use in psychiatric disorders. Drug Metab Drug Interactions 1990; 8: 159-86. 5. Vries de MH, Koning de P, Floot HL, et al. Dose-proportionality of eltoprazine: pharmacokinetics of single oral doses in healthy subjects. Eur J Clin Pharmacol 1. Van
1991; 41: 485-88.
Psychiatric aspects of loin pain/haematuria syndrome SIR,-In your Sept 19 editorial you recommend renal autotransplantation in selected cases of loin pain/haematuria syndrome (LPH), largely on the basis of a series of 10 patients.We are concerned that in emphasising a surgical cure you fail to give due attention to important psychological aspects of LPH that are highly relevant to these patients’ particular therapeutic needs. Psychological features were emphasised in the original 1967 report2 in which the 3 patients were described as "anxious, introspective and demanding of medical attention, occasionally fabricating medical evidence". We have done detailed psychiatric assessments of 15 patients with LPH from a series of 25, whose clinical details we have reported.3 A 2-3 h semi-structured interview was aimed at an understanding of the development of the condition in the context of the individual’s life history. In addition, the patients were assessed for current and life-time psychiatric illness. Various self-report rating scales were also used. We investigated 3 men and 12 women (age 30-63 years, mean 46-5, SD 9-0). Age at onset ranged from 15 to 43 years (29-7, 88) and duration of renal symptoms was 5-36 years (16-6, 96). 7
JL. Loin pain-hematuna syndrome: role for renal autotransplantation. J Urol 1992; 147: 987-89. 2. Little PJ, Sloper JS, De Wardener HE. A syndrome of loin pain and haematuria associated with disease of the peripheral renal arteries. QJ Med 1967; 142: 253-59 3. Leaker BR, Gordge MP, Patel A, Neild GH. Haemostatic changes in the loin pain haematuria syndrome: secondary to renal vasospasm? QJ Med 1990; 281: 967-79 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd ed. Washington DC: American Psychiatric Association, 1987. 5. Benjamin S, Eminson DM. Abnormal illness behaviour: childhood experiences and long term consequences. Int Rev Psychiatry 1992; 4: 55-70. 6. Hutchmson SM, Doig A, Jenkms AM. Recurrence of loin pain haematuria syndrome after renal autotransplantation. Lancet 1987; i: 1501-02. 7. Gazder AF, Dammin GJ. Neural degeneration and regeneration m human renal transplant. N Engl J Med 1970; 283: 222-24.
Nitric oxide during hand ventilation in patient with acute respiratory failure SIR,-Some patients with severe acute respiratory failure are so on a high fraction of inspired oxygen (Fi02) and an increased mean airway pressure that it is impossible to disconnect them from the mechanical ventilator for physiotherapy. We have used nitric oxide administered by hand ventilation in such a case to maintain adequate arterial oxygenation. An 8-year-old boy was transferred from another hospital to our intensive care unit with severe acute respiratory failure after liver transplantation. The clinical, haemodynamic, respiratory, and chest radiographic features were consistent with an acute lung injury associated with sepsis (ie, adult respiratory distress syndrome [ARDS]). The child initially required pressure-controlled ventilation (PCV) with Fi02 1-0, 15 cm Hz0 of positive endexpiratory pressure (PEEP), and a long inspiratory time (inhalation/
dependent
exhalation [1/E] ratio 2/1). With the introduction of inhaled nitric oxide (10 parts per million [ppm] measured by chemiluminescence [Model 42, ThermoElectron]), Fi02 could be reduced to 0-7 while arterial oxygenation improved. It was impossible, however, to hand-ventilate the patient safely on an Fi02 of 1.0 for standard physiotherapy. When this was attempted, severe life-threatening arterial desaturation occurred. Thus we devised a circuit that allowed the administration of nitric oxide during physiotherapy. After a striking improvement in the child’s clinical
RESPONSE ON ELTOPRAZINE (NATURALISTIC RATING
PROCEDURES)
*DSM-III-R
psychotropic drugs (table). Besides moderate to severe insomnia in patients 1,3,4, and 9, no side-effects were reported. These results support the hypothesis that serotonin is involved in the pathogenesis of self-injury. The effects of eltoprazine, including those on social behaviour, seemed to diminish after 6 weeks in most of the patients. We do not know why. Mechanisms such as alterations in receptor sensitivity, changes in phannacokinetics, or overriding environmental factors might be involved. Vincent van Gogh Institute for Psychiatry, PO Box 5, 5800 AA Venray, Netherlands
St
Augustinus Institute for Mental Retardation,
Gennep
WILLEM M. A. VERHOEVEN SIEGFRIED TUINIER No A. S. SIJBEN YVONNE W. H. M. VAN DEN BERG E. P. P. M. DE WITTE-VAN DER SCHOOT
Section of Pathophysiology of Behaviour, Erasmus University,
University Hospital, Utrecht
Maudsley Hospital, London SE5 8AZ, UK
PHILIP A. LUCAS
Department of Nephrology, Institute of Urology and Nephrology, Middlesex Hospital, London
BRIAN R. LEAKER GUY H. NEILD
1 Chin
Rotterdam;
Department of Child Neurology,
subjects had paramedical backgrounds. At least 5 had taken analgesia stronger than dihydrocodeine. Preliminary results suggest that 9 of the 15 had had at least one previous episode of severe depression. Of these, only 1 had a definite depressive illness at the time of interview and 2 others were equivocal. In 7 subjects, onset had occurred after a psychologically significant event, typically a loss, that was unrelated to their medical condition. Our most striking finding concerned intra-familial relationships. A history of a childhood obligation to take care of one or both chronically sick parents was given clearly by 12 and suggested by at least 2 others. Although overt depression/anxiety is not usually a feature of LPH, we suggest that the syndrome has much in common with somatoform pain disorder, about which the Diagnostic and Statistical Manual of Mental Disorders’ states "the predominant disturbance is at least six months’ preoccupation with pain ... [and] when there is related organic pathology, the pain or resulting social or occupational impairment is grossly in excess of what would be expected from the physical fmdings". The aetiology and pathogenesis of somatoform pain disorder is poorly understood, but adults who somatise have consistently proved to have increased childhood experience of illness in close relatives, especially parents5 Recurrence of pain in the autotransplanted kidney has been reported.6 Whatever the part played by regeneration of autonomic nerve fibres’ in the mechanism of this pain, our study suggests an important role for powerful underlying emotional dynamics. We believe that appropriate investigations, explanation, and long-term supportive care are the most important aspects of management, and are perhaps most satisfactorily delivered by an experienced renal physician together with a multidisciplinary team, including psychiatric colleagues.
LOLKE PEPPLINKHUIZEN ONNO VAN NIEU WENHUI ZEN
Praag HM. Serotonergic dysfunction and aggression control: serotonin and (auto-)aggressive behavior. Psychol Med 1991; 21: 15-19. 2. Markowitz PI. Fluoxetine treatment of self-injurious behavior in mentally retarded patients. J Clin Psychopharmacol 1990; 10: 299-300. 3. Primeau F, Fontaine R. Obsessive disorder with self-mutilation- a subgroup responsive to pharmacotherapy. Can J Pychiatry 1987; 32: 699-700. 4. Rasmussen DL, Olivier B, Raghoebar M, Mos J. Possible clinical applications of serenics and some implications of their preclinical profile for their clinical use in psychiatric disorders. Drug Metab Drug Interactions 1990; 8: 159-86. 5. Vries de MH, Koning de P, Floot HL, et al. Dose-proportionality of eltoprazine: pharmacokinetics of single oral doses in healthy subjects. Eur J Clin Pharmacol 1. Van
1991; 41: 485-88.
Psychiatric aspects of loin pain/haematuria syndrome SIR,-In your Sept 19 editorial you recommend renal autotransplantation in selected cases of loin pain/haematuria syndrome (LPH), largely on the basis of a series of 10 patients.We are concerned that in emphasising a surgical cure you fail to give due attention to important psychological aspects of LPH that are highly relevant to these patients’ particular therapeutic needs. Psychological features were emphasised in the original 1967 report2 in which the 3 patients were described as "anxious, introspective and demanding of medical attention, occasionally fabricating medical evidence". We have done detailed psychiatric assessments of 15 patients with LPH from a series of 25, whose clinical details we have reported.3 A 2-3 h semi-structured interview was aimed at an understanding of the development of the condition in the context of the individual’s life history. In addition, the patients were assessed for current and life-time psychiatric illness. Various self-report rating scales were also used. We investigated 3 men and 12 women (age 30-63 years, mean 46-5, SD 9-0). Age at onset ranged from 15 to 43 years (29-7, 88) and duration of renal symptoms was 5-36 years (16-6, 96). 7
JL. Loin pain-hematuna syndrome: role for renal autotransplantation. J Urol 1992; 147: 987-89. 2. Little PJ, Sloper JS, De Wardener HE. A syndrome of loin pain and haematuria associated with disease of the peripheral renal arteries. QJ Med 1967; 142: 253-59 3. Leaker BR, Gordge MP, Patel A, Neild GH. Haemostatic changes in the loin pain haematuria syndrome: secondary to renal vasospasm? QJ Med 1990; 281: 967-79 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 3rd ed. Washington DC: American Psychiatric Association, 1987. 5. Benjamin S, Eminson DM. Abnormal illness behaviour: childhood experiences and long term consequences. Int Rev Psychiatry 1992; 4: 55-70. 6. Hutchmson SM, Doig A, Jenkms AM. Recurrence of loin pain haematuria syndrome after renal autotransplantation. Lancet 1987; i: 1501-02. 7. Gazder AF, Dammin GJ. Neural degeneration and regeneration m human renal transplant. N Engl J Med 1970; 283: 222-24.
Nitric oxide during hand ventilation in patient with acute respiratory failure SIR,-Some patients with severe acute respiratory failure are so on a high fraction of inspired oxygen (Fi02) and an increased mean airway pressure that it is impossible to disconnect them from the mechanical ventilator for physiotherapy. We have used nitric oxide administered by hand ventilation in such a case to maintain adequate arterial oxygenation. An 8-year-old boy was transferred from another hospital to our intensive care unit with severe acute respiratory failure after liver transplantation. The clinical, haemodynamic, respiratory, and chest radiographic features were consistent with an acute lung injury associated with sepsis (ie, adult respiratory distress syndrome [ARDS]). The child initially required pressure-controlled ventilation (PCV) with Fi02 1-0, 15 cm Hz0 of positive endexpiratory pressure (PEEP), and a long inspiratory time (inhalation/
dependent
exhalation [1/E] ratio 2/1). With the introduction of inhaled nitric oxide (10 parts per million [ppm] measured by chemiluminescence [Model 42, ThermoElectron]), Fi02 could be reduced to 0-7 while arterial oxygenation improved. It was impossible, however, to hand-ventilate the patient safely on an Fi02 of 1.0 for standard physiotherapy. When this was attempted, severe life-threatening arterial desaturation occurred. Thus we devised a circuit that allowed the administration of nitric oxide during physiotherapy. After a striking improvement in the child’s clinical
