Lithium is a mood stabilizer often used as a first-line treatment for bipolar disorder. Its narrow therapeutic window and changes in the absorption, distribution, and elimination of the drug following bariatric surgery have important implications regarding patient safety.

We present a 51-year-old female patient with bipolar disorder and a medical history of morbid obesity, type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, and essential hypertension. She was mentally stable on lithium 1200 mg/day, valproate 500 mg/day, and quetiapine 400 mg/day. She had undergone laparoscopic sleeve gastrectomy. After a month, she showed up to the emergency room (ER) with nausea, vomiting, diarrhea, and fatigue. Gastroenteritis was suspected until the patient started showing neurological symptoms such as delirium, dysarthria, ataxia, chorea, and athetosis.

The patient was monitored and received aggressive intravenous hydration (3000 cc of 0.9% serum isotonic) in the intensive care unit (ICU). She was prescribed intramuscular biperiden injection of 5 mg/ml/day, pheniramine 45.5 mg/2 ml/day, and lorazepam 1 mg/day. Her lithium levels were checked every six hours. She was agitated and disoriented for the first five days despite lithium levels being in the therapeutic range. On day six, her blood lithium levels dropped to 0.399 mmol/L. Her psychiatric examination revealed that she resumed cooperation and orientation, her dysarthria subsided. However, her thought content and attitude were grandiose, and she had a labile affect. We prescribed 5 mg/day of olanzapine routinely and 1 mg/day of lorazepam on a needed basis. The next day, her labile affect became calmer, and her sleep improved so she was discharged from the ICU and admitted to general surgery inpatient service, and olanzapine was titrated to 10 mg per day since she had elevated mood symptoms.

After 7 days of intravenous hydration and supportive treatment, her neurological symptoms completely subsided except for a fine tremor, which lasted for another 3 days and then ceased. She was clinically stabilized without further need for intervention. Her lithium level was 0.206 mmol/L before her discharge.

We believe it is of utmost importance to build a consensus in guidelines and inform physicians about lithium toxicity and its symptoms after bariatric surgeries. We recommend a careful follow-up of the patient pre-and postoperatively. Preoperative psychiatric intervention includes decreasing the lithium dose gradually and discontinuing it. After the operation, lithium can be started with a much lower dose and may be increased by checking lithium levels every week for at least 6 weeks after the operation until the patient can digest solid food again, and then every 2 weeks for 6 months, and thereafter every month for one year.

None Declared

Adherence to palivizumab prophylaxis programmes is crucial to protect infants with CHD against respiratory syncytial virus infections. We analysed the effectiveness of two nudge interventions in increasing adherence.

Our study included 229 infants, and their caregivers, from five centers in Turkey in the 2020–2021 respiratory syncytial virus season. We randomly allocated caregivers to a control and two intervention groups. Caregivers in all groups were informed about the prophylaxis programme and provided a schedule. Additionally, caregivers in Intervention 1 were called two days before appointments (default bias) and were asked to plan the appointment day (implementation intention), whereas caregivers in Intervention 2 received biweekly text messages informing them about the programme’s benefits (availability bias) and current adherence rate (social norm).

Caregivers in Intervention 1 had a significantly higher adherence rate than Control (97.3% versus 90.9%) (p = 0.014). Both interventions had a significant effect on participants in their first prophylaxis season (p = 0.031, p = 0.037). Families where the father was employed had a 14.2% higher adherence rate (p = 0.001). Every additional child was associated with a 2.2% decrease in adherence rate (p = 0.02). In control, ICU admission history was associated with an 18.8% lower adherence rate (p = 0.0001), but this association disappeared in intervention groups.

This is the first prospective interventional study which, in the context of palivizumab prophylaxis, analyses the effectiveness of nudge interventions based on established cognitive biases by comparing randomly generated intervention and control groups. We found that default bias and implementation intention have significant effects on adherence.

Clinical trial, in the name and number “Adherence of palivizumab prophylaxis, NCT05778240” registered retrospectively. https://clinicaltrials.gov/ct2/show/NCT05778240.

Vesicoureteral reflux is a prominent congenital anomaly of the kidney and the urinary tract. Further, renal scarring is known to be related to chronic inflammation. However, there have been limited studies to date regarding the cardiovascular consequences of vesicoureteral reflux.

The aim of this study is to evaluate the possible subclinical atherosclerosis and cardiovascular complications in children with vesicoureteral reflux.

Patients with vesicoureteral reflux and age matched healthy controls were prospectively included in this case-control study. Patients were divided into two groups concerning renal scarring status. To assess cardiac functions, carotid artery intima media, epicardial adipose tissue, and periaortic adipose tissue thicknesses were evaluated.

There were 50 patients with vesicoureteral reflux; 26 patients without renal scarring and 24 patients with renal scarring, as well as 40 healthy controls. Myocardial performance indexes (Tei indexes) measured by tissue Doppler echocardiography from septum and left ventricle were significantly increased in study group (for all, p < 0.001). Also, intima media, epicardial adipose tissue, and periaortic adipose tissue thicknesses of the study groups were significantly higher than the control group (for all, p < 0.001). However, no statistical difference was observed between renal scarring (−) and renal scarring (+) groups.

Results of our study showed early deterioration of cardiac systolic and diastolic functions in children with vesicoureteral reflux regardless of renal scarring. Also, diagnosis of vesicoureteral reflux is an important risk factor for subclinical atherosclerosis, independent of renal scarring, which should be considered in the follow-up of these patients.

Dignity therapy (DT) is a brief, individualized intervention, which provides terminally ill patients with an opportunity to convey memories, essential disclosures, and prepare a final generativity document. DT addresses psychosocial and existential issues, enhancing a sense of meaning and purpose. Several studies have considered the legacy topics most frequently discussed by patients near the end of life. To date, no Portuguese study has done that analysis.

We conducted a qualitative analysis of 17 generativity documents derived from a randomized controlled trial (RCT). Inductive content analysis was used to identify emerging themes.

From the 39 RCT participants receiving DT, 17 gave consent for their generativity document to undergo qualitative analysis. Nine patients were female; mean age of 65 years, with a range from 46 to 79 years. Seven themes emerged: “Significant people and things”; “Remarkable moments”; “Acknowledgments”; “Reflection on the course of life”; “Personal values”; “Messages left to others”; and “Requests and last wishes”.

Generativity document analysis provides useful information for patients nearing death, including their remarkable life moments and memories, core values, concerns, and wishes for their loved ones. Being conscious of these dominant themes may allow health providers to support humanized and personalized care to vulnerable patients and their families, enhancing how professionals perceive and respond to personhood within the clinical setting.

Total anomalous pulmonary venous connection is a rare cyanotic CHD that requires surgical repair. An unligated vertical vein after total anomalous pulmonary venous connection surgery may help to decrease the episodes of post-operative pulmonary hypertensive crises, low cardiac output syndrome, and mortality. The aim was to assess long-term outcome and our post-operative transcatheter vertical vein closure experiences in five patients with repaired total anomalous pulmonary venous connection patients.

A retrospective study was conducted in five cases with an unligated vertical vein following repair of supra-cardiac total anomalous pulmonary venous connection at our hospital from 2011 through 2018. Patients characteristics, cardiac catheterisation findings, surgical, and transcatheter procedural details were retrospectively analysed.

Transcatheter closure of the unligated vertical vein was technically successful in all the patients. Procedure-related complications were not observed in any of the patients. No long-term complication was found.

We suggest that transcatheter closure of the patent vertical vein is an effective and well-tolerated alternative to the surgical approach.

Lower respiratory tract infections caused by respiratory syncytial virus can be severe during infancy, which requires admission to the hospital. These infections may be more severe especially in patients with congenital heart disease. Passive immunisation with palivizumab, a monoclonal antibody, is recommended in high-risk infants. We tried to determine the compliance rates, factors affecting compliance, and also other microorganisms responsible for lower respiratory tract infections after palivizumab prophylaxis in these patients.

We evaluated patients’ compliance to prophylaxis with palivizumab in two consecutive respiratory syncytial virus seasons from pharmacy records. We also investigated factors affecting compliance and the frequency of hospitalisations for lower respiratory tract infections. We investigated the causative microorganisms detected in hospitalised patients.

In this study, 86.7% of the desired number of injections was achieved in 176 patients in two seasons. Out of these, 117 patients (66.4%) received all the doses they were prescribed. Although not statistically significant, compliance to prophylaxis was higher in male patients, cyanotic patients, those who started under 1 year old, and who lived in the city centre. Human metapneumovirus, parainfluenza type 3, and bocavirus were detected in the hospitalised patients.

Patients with congenital heart disease can survive the period of infancy with less problem by making palivizumab prophylaxis more effective, and awareness about non- respiratory syncytial virus factors may be a guide for the development of new treatments.

Early life stressful events cause long-term neural changes that are associated with psychiatric disorders.

Early life manipulations focus on commonly the impact of remaining separate from the mother in a specific period of time. The maternal odor is required for pups to approach the mother for nursing. What happens when there is a mother that smell like a real mother but does not take care her own pups?

To investigate the fake mother effects on adult rat's behavioral changes, NMDR2B protein level changes in prefrontal cortex and hippocampus.

Wistar rats were used. Fake mother (n:13), early handling (n:12), maternal separation (n:14) and control (n:12) were the study groups. A fake mother is an object that smells like a real dam. When the real mother is separated from own pups fake mother stays with the pups for an hour. Manipulations were made during the postnatal first 14 days. Behavioral tests (social interaction test, elevated plus maze, novel object recognition test) were made between postnatal 62 and 78 days. NMDAR2B protein levels in prefrontal cortex and hippocampus were evaluated by using ELISA at postnatal 78 days.

In social interaction test, fake mother group exhibited less social behavior and more aggressive behavior than the other groups. Their long-term memory functions were the lowest. NMDAR2B protein levels in the hippocampus increased in rats that exposed to early stressful life events.

These results support that being raised by fake mother increases aggressive behavior and decrease social behavior in adulthood.

The authors have not supplied their declaration of competing interest.

Thirty-five definite vestibuler migraine patients (according to Neuhauser criteria), 35 MO patients and 32 healthy controls were included. All patients were evaluated for their lifetime psychiatric disorders with Structured Clinical Interview for DSM–IV/Clinical version (SCID-I/CV). All three groups evaluated by:

– Hamilton Anxiety Rating Scale (HARS);

– State-Trait Anxiety Inventory (STAI), (STAI-X1) and the other trait anxiety STAI-X2);

– Beck depression inventory (BDI);

– Lifetime Panic Agoraphobic Spectrum Scale (PAS-SR);

– Penn State Worry Questionnaire (PENN);

– Separation Anxiety Symptoms Inventory (SASI);

– Adult Separation Anxiety Questionnaire (ASA).

Psychiatric diagnosis history (SCID-I); comparison of VM and MO did not indicate a significant difference (P < 0.05). VM and MO patients were significantly different than HC in terms of anxiety symptoms in “HAM-A, PENN, ASA, PAS-SR and PAS-SR subscales (P < 0.05)”. VM was significantly different than MO patients in BDE and PAS-SR (overall; separation anxiety, agoraphobia, reassurance seeking) (P < 0.05). The longer the history of migraine the higher was the anxiety points in both in VM and MO patients (P < 0.05). Headache and vertigo severity in VM patients were significantly correlated with the elevated anxiety and depression points (P < 0.05).

VM and MO patients significantly different in anxiety and mood disorder when compared with healthy controls. Our findings showed that VM patients were more vulnerable to psychiatric disorders. For that reason, multidisciplinary approach for the treatment of VM may facilitate the treatment process.

The authors have not supplied their declaration of competing interest.

This study evaluated cardiac function using tissue Doppler echocardiography and assessed electrocardiographic findings in children diagnosed with Wilson’s disease.

Asymptomatic patients with a diagnosis of Wilson’s disease (n = 43) were compared to healthy controls (n = 37) that were age and gender matched.

The standard electrocardiographic and conventional echocardiographic examinations were similar in both groups. The left ventricular ejection fraction, shortening fraction, and diastolic function were not significantly different between the two groups. The Tei index for mitral lateral, mitral septal, tricuspid lateral, tricuspid septal, and inter-ventricular septum on tissue Doppler echocardiography was higher in the patient group, yet it did not reach statistical significance. Mitral lateral and septal systolic annular velocity values were significantly lower in the patient group when compared to the control group (p = 0.02 and 0.04, respectively). Also, mitral lateral and septal isovolumetric contraction time values were higher in the patient group (p = 0.04). Although the left ventricular values were not significantly different, relative left ventricular wall thickness was higher in the patient group when compared to the control group, and concentric remodelling in the left ventricle was found in 7 (16%) of 42 patients. QT interval (p = 0.02) and P-wave dispersion values (p = 0.04) were significantly higher in the patient group compared to the control group, and these tend to predict arrhythmias.

Our study based on the tissue Doppler echocardiography assessment indicated a subclinical systolic, rather than diastolic, dysfunction in the myocardium with increased QT interval and P-wave dispersion, despite the young age of the patients and short disease duration.