To assess the associations between nutrient intake and dietary patterns with different sarcopenia definitions in older men.

Cross-sectional study.

Sarcopenia was defined using the Foundation for the National Institutes of Health (FNIH), the European Working Group on Sarcopenia in Older People (EWGSOP) and the European Working Group on Sarcopenia in Older People 2 (EWGSOP2). Dietary adequacy of fourteen nutrients was assessed by comparing participants’ intakes with the Nutrient Reference Values (NRV). Attainment of NRV for nutrients was incorporated into a variable ‘poor’ (meeting ≤ 9) v. ‘good’ (meeting ≥ 10) using the cut-point method. Also, two different dietary patterns, monounsaturated:saturated fat and n-6:n-3 fatty acids ratio and individual nutrients were used as predictor variables.

A total of 794 men aged ≥75 years participated in this study.

The prevalence of sarcopenia by the FNIH, EWGSOP and EWGSOP2 definitions was 12·9 %, 12·9 % and 19·6 %, respectively. With the adjustment, poor nutrient intake was significantly associated with FNIH-defined sarcopenia (OR: 2·07 (95 % CI 1·16, 3·67)), but not with EWGSOP and EWGSPOP2 definitions. The lowest and second-lowest quartiles of protein, Mg and Ca and the lowest quartiles of n-6 PUFA and n-3 PUFA intakes were significantly associated with FNIH-defined sarcopenia. Each unit decrease in n-6:n-3 ratio was significantly associated with a 9 % increased risk of FNIH-defined sarcopenia (OR: 1·09 (95 % CI 1·04, 1·16)).

Inadequate intakes of nutrients are associated with FNIH-defined sarcopenia in older men, but not with the other two sarcopenia definitions. Further studies are required to understand these relationships.

To examine changes in micronutrient intake over 3 years and identify any associations between socio-economic, health, lifestyle and meal-related factors and these changes in micronutrient intakes among older men.

Prospective study.

Dietary adequacy of individual micronutrient was compared to the estimated average requirement of the nutrient reference values (NRV). Attainment of the NRV for twelve micronutrients was incorporated into a dichotomised variable ‘not meeting’ (meeting ≤ 6) or ‘meeting’ (meeting ≥ 7) and categorised into four categories to assess change in micronutrient intake over 3 years. The multinomial logistic regression analyses were conducted to model predictors of changes in micronutrient intake.

Seven hundred and ninety-four men participated in a detailed diet history interview at the third wave (baseline nutrition) and 718 men participated at the fourth wave (3-year follow-up).

The mean age was 81 years (range 75–99 years). Median intakes of the majority of micronutrients decreased significantly over a 3-year follow-up. Inadequacy of the NRV for thiamine, dietary folate, Zn, Mg, Ca and I were significantly increased at a 3-year follow-up than baseline nutrition. The incidence of inadequate micronutrient intake was 21 % and remained inadequate micronutrient intake was 16·4 % at 3-year follow-up. Changes in micronutrient intakes were significantly associated with participants born in the UK and Italy, low levels of physical activity, having ≥2 medical conditions and used meal services.

Micronutrient intake decreases with age in older men. Our results suggest that strategies to improve some of the suboptimal micronutrient intakes might need to be developed and implemented for older men.

Alert for the efficiency of the clozapina, in high doses, in refractory mania to pharmacological treatment.

Review of literature relevant after the description of a clinical case example.

Description of a clinical case: Woman 30 years, ethnicity african, with bipolar disease type 1, with 12 years of evolution, and 11 treatments with around 1 year duration. Specifics took place with medication, such as intolerance to mood stabilizers, including lithium and valproate. Last inpatient care, with 5 months, it was for outbreak manic characterized by huge dysphoria and easy irritability with aggressiveness. There were administered antipsychotics, in high doses, and attempted electroconvulsive therapy, without success. Clinical remission has been achieved by the gradual increase of clozapina, in accordance with the patient tolerance, until 1400 mg daily without occurrence of agranulocytosis. The only intercurrence was a epileptic seizure, controlled with phenytoin.

Refractory mania is treated with clozapina in high doses, which must be administered according to the patient tolerance and clinical improvement. The risk of agranulocytosis (1-3%) is low, and is the only formal indication to suspend the treatment. The extensive metabolizers do not respond to conventional doses of psychotropic substances, they need larger doses and are more frequent in african people.

Intellectual disability (ID) is defined as significantly subaverage intellectual functioning with deficits in adaptive behavior. For ∼40% of individuals, cause for disability remains unknown and these are categorized as idiopathic ID (IID). Various behavioral problems co-occur with ID and thus serotonergic neurotransmission, known to control emotion, mood and drive, has received immense attention. Synaptic serotonin (5-HT) level is primarily maintained by metabolizing enzyme MAOA and serotonin transporter (SLC6A4) which helps in reuptake of the neurotransmitter. Since functional genetic polymorphisms have a potency to affect activities of these proteins, in the present investigation polymorphisms in these genes (MAOA-u VNTR, rs6323, 5-HTTLPR and STIN2) have been analyzed in IID individuals associated with various behavioral problems.

Families (N=189) with IID probands were recruited following DSM-IV. After obtaining informed written consent for participation, peripheral blood was collected for isolation of genomic DNA used for PCR-based genotyping of target sites followed by family-based statistical analyses of data.

Significant association of MAOA rs6323 “T” allele with female IID (P=0.016) and a trend towards association with female IID patients exhibiting behavioral problems (P=0.046) was noticed. Non significant over transmission of the 5-HTTLPR “L” allele was also observed in female IID probands with behavioral problems (P=0.076). Synergistic epistatic interaction, with a sex-bias, was noticed between MAOA and 5-HTT (P< 0.05).

From the data obtained it could be summarized that serotonergic system may have some role in the etiology of behavioral problems of female IID individuals.

To alert to manic like symptoms in frontotemporal dementia (FTD).

Review of literature relevant in medline database.

Frontotemporal dementia (FTD) is a behavioural syndrome caused by generation of the frontal and anterior temporal lobes.

Bipolar disorder in dementia and the temporal relation between the two conditions have rarely been studied. There is a increased probability of developing a manic episode in patients with dementia.

Those with temporal FTD have impairments in emotional processing and hypomania like behavior. Moria (childish excitement or tendency to joke) or frivolous excitement are common presenting symptoms, and is difficult to distinguish to features in bipolar disease.

The correlation between mania like symptoms and FTD can be make with the help of informations of the family and computed tomography imaging. Those with temporal involvement are particularly at risk of developing deficits in emotional processing secondary to atrophy in the amygdale, anterior temporal cortex, and adjacent orbitofrontal cortex.

Early temporal involvement in FTD is associated with frivolous behavior and right temporal involvement is associated with emotional disturbances.

Moria or frivolous behavior are common presenting symptoms of FTD and the differential diagnosis is made with the help of informant's reports and computed tomography imaging.

Alert to the high prevalence and familial association between schizophrenia and mental retardation.

Review relevant literature after the description if a clinical case example; additional diagnostic exams.

Description of a clinical case: Man with 25 years old with mental retardation and first episode of pchicosys.

He and his all family works in the fire department. In his family history there is a mother with pchicosys, father with mental retardation, sister with a post partum depression, aunt with bipolar affective disorder, and two uncles who comet suicide.

In January of 2008, he begins to hear voices, in his work, that call him and ask for help; then he begin to see an old lady in his bedroom's window; he stop sleeping and eating. The family brings him to the emergency room and he's started diazepam (15 mg/day) and olanzapina (20 mg/day) and the symptom remit.

Three days later, he stops the medication and the symptoms came back. He gets very scared and begin to take the medication every day.

He did a brain computerized tomography that excludes organic diseases and psychological tests that confirms mental retardation.

It is well established that prevalence of schizophrenia is around three times greater in those with mild mental retardation and the co-association between mental retardation and schizophrenia is highly familial. Both bipolar illness and major depressive disorder have also increased prevalence in the mental retarded. The prognosis is directly linked with family and social support.

To alert to apathy as a sub-syndrome in the spectrum dementia-depression.

Review of literature relevant in medline database.

The modern concept of apathy implies a reduced volition. Apathy may occur in depression and dementia and the differential diagnosis is difficult. Symptoms of apathy may constitute a sub-syndrome in the spectrum depression-dementia, that are characterized by lack of interest, psychomotor retardation, loss of energy and loss of appetite. Apathy may occur in dementia without depression and is significantly associated with more severe cognitive deficits. In dementia, depression may primarily result from a combination of symptoms of anxiety and apathy. Most patients with dementia and apathy had concomitant depression, but less depressed patients had concomitant apathy. The key to diagnosis may be the mood symptoms: dysthymia could be a negative emotional reaction to the progressive cognitive decline in dementia, whereas major depression could more strongly related to biological factors.

The nosological position of apathy remains obscure, with some studies suggesting that apathy and depression are independent constructs, and other studies showing a significant overlap between apathy and depression. The major interest to the type of syndrome has therapeutics implications.

Knowing the impact that religious beliefs can have on the etiology, diagnosis and course of psychiatric disorders will help psychiatrists better understand their patients, assessing when the religious or spiritual beliefs are used to cope with mental illness and when they may be exacerbating this disease.

Alert to the importance of religion in clinical practice.

Relevant literature review.

Several studies have demonstrated the influence of spirituality on physical, mental and health. In 1988, the World Health Organization (WHO) has given rise to the interest in further investigations in this area, with the inclusion of a spiritual aspect of the multidimensional concept of health. The spiritual well-being can be considered a protective factor for psychiatric disorders.

Although it is not possible to determine with accuracy, the mechanisms of interaction of spirituality on health, especially mental health, several studies suggest that exercise can influence the spiritual activities, psychodynamically, through positive emotions. Furthermore, these emotions may be important for mental health in terms of possible psychophysiological and psychoneuroimmunological mechanisms.

Anthropological sources suggest that beliefs in demons, black magic and evil spirits as cause of mental illness and distress are common. They may be less prevalent in western countries but even in Europe it's possible to see patients thought that their condition have been caused by evil and occult possession.

Clinicians should understand the negative and positive roles that religion plays in those with mental disorders and use this in clinical practice.

The presence of cognitive dysfunction in bipolar disorder is well established, but in the euthymic phase appear a few studies that point to the absence of cognitive deficits.

Alert to cases of euthymic bipolar disorder with no cognitive dysfunction.

Review of relevant literature and description of a clinical case with psychological tests that assess memory and executive functions.

Description of a clinical case: FP is a middle age woman, early retired, with a bipolar disorder type 2, which begins at age 30.

Her disease has several depressive episodes, and in the last 10 years, she spent most of the days lying in bed and repeatedly resorted to the emergency department for excessive voluntary drug intoxication or simply because she “wanted” to be hospitalized; her husband could not stand this situation. In September of 2009, in addition to the medical and psychological consultations, she starts attending group therapy; over the next 6 months her medication was changed and finally her disease goes into remission.

The psychological tests, made at euthymic phase, show’s no significant deficits in verbal memory and executive functions.

This patient has a disease with prolonged course and multiple hospitalizations and drug treatments, but don’t present relevant cognitive deficits, which may point to the fact that cognitive impairment is determined by biological factors.

The suicide of a patient in ongoing treatment is surely among the most traumatic events in the professional life of a psychiatrist.

Alert to the psychiatrist's reactions to patient suicide.

Review of literature relevant in medline database.

A substantial proportion, estimated to range from 15% to 68%, of psychiatrists has experienced a patient suicide. A significant proportion of psychiatrists show strong negative reactions, affecting professional and personal lives at levels of distress that are frequently comparable with those seen in clinical populations. Psychiatrists develop rather classic symptoms of anxiety, depression, or acute or posttraumatic stress symptoms, and their responses are typical: in the beginning occurs shock, disbelief, denial and depersonalization; and in the second phase takes place: grief, shame and guilt (“did I listen to him?”), anger (toward the patient who did not honor a therapeutic contract), relief (for example, after the suicide of a chronically suicidal patient), and the finding of omens that the psychiatrist considered signs of the coming suicide. But they are predictors of increased distress among psychiatrists who experienced a patient suicide, and the more consistent are age, experience, individual personality and psychiatric history. Recognition of all this combined with an avoidance of isolation is an effective coping mechanism that prevents the structuring of a pathological response to the patient's suicide.

Psychiatrist's reactions to patient suicide are specific but not noted; its recognition is important to help them find appropriate coping mechanisms.