In children with PANDAS, which symptoms are least common?
E. Motoric hyperactivity, impulsivity, night-time difficulties, distractibility and inattention, emotional lability, some degree of anorexia, and separation anxiety are some of the behavioural symptoms reported in association with PANDAS. From the choices available, it appears auditory hallucinations would be the least common symptom. Two antibodies have been found to be suggestive of PANDAS, D8/17 and-anti basal ganglia antibody. Both are not specific for PANDAS. Rising antistreptolysin O (ASO) or anti-DNAse B titres are suggestive of recent GABHS infection.
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Which is the most common site for the primary tumour in a metastatic brain cancer?
A. Of patients with intracerebral metastases, 40% originate in the lung, 20% are from breast tumours, 10% are melanomas, 7% arise from the genitourinary tract, 7% from the GIT, and 5% are of gynaecological origin.
A 40-year-old lady with multiple sclerosis (MS) was diagnosed with depression. She is on a number of medications for her MS. Of the following medication she is on, which is most likely to be associated with depressive symptoms?
D. All of the present neuromedical treatments for MS including, corticosteroids, betainterferons, glatiramer acetate, and immunosuppressants, are suspected to affect mood, at least in some individuals. Corticosteroids are associated with euphoria initially and long-term intake could lead to a depressive state. Initial studies of interferon beta-1b, an immunomodulatory cytokine used to reduce MS disease activity over prolonged periods, found increases in depression following initiation of treatment, and increased risk of suicide attempts. More recent studies have shown that this association may not be as robust as it was thought before. In fact, at least one study has shown that baseline depression levels actually drop following treatment with the medication. It is now thought that baseline or previous history of depression is more likely to predict the development of depressive symptoms during treatment. The BNF has a warning note asking clinicians to avoid the prescription of interferon beta in patients who have a history of severe depression and suicidal ideation. Depression is also a side-effect of Baclofen, but the association is less than with interferon beta.
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John is a 30-year-old man being treated for psychotic depression with selective serotonin uptake inhibitors (SSRIs) and antipsychotics. He takes an overdose of his medications and is admitted to the medical unit with features of tremor and hyperthermia. He does not know which medications he has taken.
Which of the following points to a diagnosis of serotonin syndrome rather than neuroleptic malignant syndrome?
A. Neuroleptic malignant syndrome occurs in the setting of antipsychotic use or the sudden withdrawal of dopaminergic drugs and is characterized by ‘lead-pipe‘ muscle rigidity, extrapyramidal side-effects, autonomic dysregulation, and hyperthermia. This disorder appears to be caused by the inhibition of central dopamine receptors in the hypothalamus, which results in increased heat generation and decreased heat dissipation. The serotonin syndrome, seen with SSRIs, monoamine oxidase inhibitors (MAOIs), and other serotonergic medications, has many overlapping features, including hyperthermia, but may be distinguished by the presence of diarrhoea, tremor, and myoclonus rather than the lead-pipe rigidity of neuroleptic malignant syndrome.
James was admitted to the medical unit following an attempt of deliberate self-harm (DSH).
What percentage of people completes suicide within a year of the DSH attempt?
A. There is a clear link between DSH attempt and suicide, with 15–25% of those who die by suicide having presented with an episode of DSH in the year prior to their death. Between one-third and two-thirds of those who commit suicide having a lifetime history of DSH. About 0.7–1.0% of DSH patients die within a year by suicide. This is approximately 66 times the annual risk of suicide in the general population in the UK. There appears to be marked variability between different groups, with rates of suicide following DSH increasing markedly with age at initial presentation, living alone, and in those with multiple episodes of DSH. Males have almost twice the risk of females of committing suicide following an episode of DSH, especially in the following year.
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