Download The Lancet ~ Volume 373, Issue 9657, Pages 1-94 (3 January 2009-9 January 2009) PDF

TitleThe Lancet ~ Volume 373, Issue 9657, Pages 1-94 (3 January 2009-9 January 2009)
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LanguageEnglish
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Table of Contents
                            S0140673609X60575_cov150h
sdarticle
sdarticle(1)
sdarticle(2)
sdarticle(3)
	When childhood dies
		References
sdarticle(4)
	The spurious advance of antipsychotic drug therapy
		References
sdarticle(5)
	Assessing bleeds clinically: what’s the score?
		References
sdarticle(6)
	Can antiretroviral therapy eliminate HIV transmission?
		References
sdarticle(7)
	Treating our way out of the HIV pandemic: could we, would we, should we?
		References
sdarticle(8)
	Malaria scale-up progress: is the glass half-empty or half-full?
		References
sdarticle(9)
	Helsinki discords: FDA, ethics, and international drug trials
		References
sdarticle(10)
	Cardiology: a call for papers
sdarticle(11)
sdarticle(12)
sdarticle(13)
sdarticle(14)
sdarticle(15)
	Paulo Seacutergio Pinheiro: giving a voice to children
sdarticle(16)
sdarticle(17)
sdarticle(18)
	The fragmented clinical record: a risk to at-risk children
		References
sdarticle(19)
	Association between cerebral palsy and erythromycin
		References
sdarticle(20)
	Association between cerebral palsy and erythromycin
		References
sdarticle(21)
	Association between cerebral palsy and erythromycin
		References
sdarticle(22)
	Treatment of extensively drug-resistant tuberculosis
		References
sdarticle(23)
	Treatment of extensively drug-resistant tuberculosis
		References
sdarticle(24)
	Treatment of extensively drug-resistant tuberculosis
		References
sdarticle(25)
	Unsexy tuberculosis
		References
sdarticle(26)
	Intermittent preventive treatment with antimalarial drugs
		References
sdarticle(27)
	Intermittent preventive treatment with antimalarial drugs
		References
sdarticle(28)
	Computerised clinical decision support in rural China
		References
sdarticle(29)
	Antibiotic resistance in China—a major future challenge
		References
sdarticle(30)
	Department of Error
sdarticle(31)
	Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis
		Introduction
		Methods
			Search
			Data extraction and outcome variables
			Meta-analytical calculations
			Role of the funding source
		Results
			Search
			Outcomes
			Effects of blinding
			Overall efficacy
			Specific psychopathology
			Relapse
			Quality of life
			Side-effects
			Extrapyramidal side-effects
			Weight gain
			Sedation
			Effects of comparator dose
			Prophylactic antiparkinsonian medication
			Industry sponsorship
		Discussion
		Acknowledgments
		References
sdarticle(32)
	Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation
		Introduction
		Methods
			Data collection
			Statistical analysis
			Role of the funding source
		Results
		Discussion
		References
sdarticle(33)
	Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model
		Introduction
		Methods
			Study design
			Stochastic model
			Deterministic transmission model
			Cost analysis
			Role of the funding source
		Results
		Discussion
		Acknowledgments
		References
sdarticle(34)
	Insecticide-treated net coverage in Africa: mapping progress in 2000–07
		Introduction
		Methods
			ITN coverage data
			Definition of poverty
			Children at risk of P falciparum transmission
			Definition of projected population estimates for 2007
			Role of the funding source
		Results
		Discussion
		Acknowledgements
		References
sdarticle(35)
	Burden and consequences of child maltreatment in high-income countries
		Introduction
		Burden of child maltreatment and definitions
		Determinants of maltreatment
			Characteristics of the victim
			Characteristics of the parents and community
			Changes over time
			Differences between countries
		Death from child maltreatment
		Long-term consequences of child maltreatment
			Education and employment
			Mental-health outcomes
			Physical-health outcomes
			Aggression, crime, and violence
		Future research
		Acknowledgments
		References
sdarticle(36)
	Obstructive sleep apnoea and its cardiovascular consequences
		Introduction
		Definition and diagnosis of OSA
		Pathophysiology
		Epidemiology
			Prevalence
			Risk factors
			Association between OSA and cardiovascular diseases
		Cardiovascular effects of treating OSA
			Hypertension
			Dysglycaemia, diabetes mellitus, and atherosclerosis
			Heart failure
			Cardiac arrhythmias
			Cerebrovascular disease
		Prevention of OSAThe most important modifi
		Summary, controversies, and future challenges
		Acknowledgments
		References
sdarticle(37)
	Unexplained seizures in an infant
		References
                        
Document Text Contents
Page 2

Editorial

www.thelancet.com Vol 373 January 3, 2009 1

Oral health: prevention is key
Oral health is a neglected area of global health and has
traditionally registered low on the radar of national
policy makers. The reasons for this situation are complex
and varied. In many countries oral health is not included
in national health surveys. And, if data are collected, it is
usually in isolation from the context of general health.
Moreover, in some cultures, oral health is neglected
because teeth are seen as expendable. Dentists have also
taken little interest in advocacy to promote good oral
health, preferring to treat rather than prevent oral diseases.
And, because poor oral health aff ects morbidity more than
mortality, governments have viewed oral conditions as
less important than other, more life-threatening diseases.

Yet, globally, the burden of major oral diseases and
conditions is high. Dental caries are one of the most
common chronic diseases worldwide. 90% of people have
had dental problems or toothache caused by caries, and
in low-to-middle income countries most caries remains
untreated. Severe periodontitis aff ects 5–15% of most
populations. Oral cancer is the eighth most common
cancer worldwide and the most common in men in
southeast Asia. And 40–50% of people who are HIV
positive have oral fungal, bacterial, or viral infections.

Access to oral care is a global problem, particularly
in low-to-middle income countries. The workforce
available to treat the most common oral health
problems—dentists—are in short supply in these
nations. Whereas countries such as Germany and the UK
have one dentist per 1000 population, low-income and
middle-income countries have one dentist per 50 000
people, and in some sub-Saharan African countries the
ratio is one per 900 000 people. Dentists also cluster
in cities where populations that can aff ord treatment
usually live, leaving rural areas deprived of even the most
basic emergency dental care.

But training more dentists and building dental
clinics—the western curative model of care—is costly
and unrealistic in most low-income and middle-income
countries. Prevention of oral disease is therefore key,
largely possible, and should be a routine part of other
health professionals’ work.

What can be done? The daily use of fl uoride is the most
cost-eff ective, evidence-based approach to reduce dental
decay. Water or salt fl uoridation are possible population-
wide approaches but their implementation depends on

the development and infrastructure of the country as well
as political will and community acceptance. Promoting the
daily use of eff ective fl uoride toothpaste is a more realistic
strategy but its cost prohibits its widespread use in many
low-income and middle-income countries. Governments
can remove taxes on fl uoride toothpaste, which in some
countries represent up to 50% of the product’s price,
and they can work with manufacturers to produce lower
cost toothpaste. In the Philippines, for example—where
97% of schoolchildren aged 6 years have dental caries—a
programme that combines the promotion of daily
handwashing with soap, tooth brushing with subsidised
fl uoride toothpaste, and twice-yearly deworming, is
proving eff ective, aff ordable, and sustainable at US$0·56
per child per year.

Policies that address the risk factors for oral diseases,
such as intake of sugars and tobacco use, can also be
implemented, especially because these moves will
help reduce chronic diseases. Oral diseases and chronic
diseases, such as cardiovascular diseases, cancer, chronic
respiratory diseases, and diabetes share many common
risk factors. In 2007, a World Health Assembly resolution
called for oral health to be integrated into chronic
disease prevention programmes.

Promoting good oral health could also help countries
to achieve child-related development goals. Caries can
negatively aff ect a child’s ability to eat, sleep, and do
school work. Preliminary studies have suggested that
dental caries and related pain and sepsis might contribute
to undernutrition and low weight and height in children
in developing countries. In developed countries, studies
show that when dental caries are treated, children start
to put on weight and thrive. Oral pain is also one of the
most common reasons for school absenteeism.

Preventing oral disease is important and achievable.
Evidence-based, simple, and cost-eff ective preventive
approaches exist, but they need to be rigorously
promoted and implemented. Professionally, health
workers, including physicians, nurses, paediatricians, and
pharmacists can all deliver prevention messages about
the use of fl uoride and the risk factors for oral disease.
Politically, commitment is needed to integrate oral
disease prevention into programmes to prevent chronic
diseases and into public-health systems. Good oral
health should be everybody’s business. The Lancet

For more on the Philippines
school programme see
Development & Coorperation
2008; 49: 8–12; http://www.
inwent.org/ez/articles/082726/
index.en.shtml

The printed
journal
includes an
image merely
for illustration

Page 57

Articles

36 www.thelancet.com Vol 373 January 3, 2009

were small and not always consistent (fi gure 7; table 7;
webtable 5). Only higher doses of low-potency fi rst-
generation antipsychotic drugs than 600 mg per day
produced more extrapyramidal side-eff ects than did
clozapine, the only drug with enough studies for
assessment.

Prophylactic antiparkinsonian medication
In 11 studies of clozapine, olanzapine, or risperidone,
prophylactic antiparkinsonian medications were used by
participants in the fi rst-generation antipsychotic drugs’
groups. Only one meta-regression analysis (clozapine
for negative symptoms) was signifi cant (webtable 3). The
effi cacy eff ect sizes were in the same range as those in
the overall analysis, but the statistical signifi cance was
inconsistent and absent for risperidone. Clozapine and
olanzapine induced signifi cantly fewer extrapyramidal
side-eff ects than did fi rst-generation antipsychotic drugs
despite prophylactic antiparkinsonian medication, but
the eff ect size was relatively small. Risperidone showed
no diff erence in these side-eff ects compared with fi rst-
generation antipsychotic drugs combined with prophy-
lactic antiparkinsonian medication (webtable 6).

Industry sponsorship
There were enough non-industry sponsored studies for
only clozapine, olanzapine, quetiapine, and risperidone.
The only signifi cant diff erence between sponsored and
non-sponsored studies was noted for the eff ect of

clozapine on positive symptoms (webtable 3). Never-
theless, when industry-sponsored studies were excluded
in a sensitivity analysis, the effi cacy of this drug was
reduced (eg, an eff ect size of −0·22 for overall symptoms
compared with −0·52 when all studies were included)
but still signifi cant. Risperidone was not signifi cantly
more effi cacious than fi rst-generation antipsychotic
drugs for the overall change in symptoms when industry-
sponsored studies were excluded. The results for olanza-
pine and quetiapine were unchanged by sponsor ship
(webtable 2; webtable 7).

Other moderators did not aff ect the results in a uniform
direction, and most sensitivity analyses were consistent
with the main results (webtable 2; webtable 3). Funnel
plots did not show a potential publication bias
(webfi gure 11). Webtable 8 compares the results of
effi cacy and eff ectiveness studies.

Discussion
Four second-generation antipsychotic drugs—amisul-
pride, clozapine, olanzapine, and risperidone—were more
effi cacious than fi rst-generation drugs in the main domains
(overall change in symptoms, and positive and negative
symptoms). The other fi ve second-generation antipsychotic
drugs were only as effi cacious as fi rst-generation anti-
psychotic drugs, even in terms of negative symptoms.
Second-generation antipsychotic drugs caused fewer
extrapyramidal side-eff ects than did haloperidol, even

1·0

0·01

0·01

0·1

10

1·0

RR

RR

SGA versus haloperidol: use of antiparkinsonian medication

SGA versus low-potency FGA: at least one extrapyramidal side-effect

0·1

SG
A

b
et

te
r

SG
A

b
et

te
r

SG
A

w
or

se

Am
isu

lpr
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Clo
za

pin
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Qu
eti

ap
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Ris
pe

rid
on

e

Se
rti

nd
ole

Zip
ras

ido
ne

*

Zo
tep

ine

Ol
an

za
pin

e

Ar
ipi

pr
az

ole

Figure 4: Extrapyramidal side-eff ects
Data are relative risk (RR; 95% CI). SGA=second-generation antipsychotic drug. FGA=fi rst-generation antipsychotic
drug. *Use of antiparkinsonian medication.

Number of
studies

Number of
participants

Relative risk
(95% CI)

p value

SGA versus haloperidol*

Amisulpride 8 783 0·58 (0·45–0·76) <0·0001

Aripiprazole 4 1794 0·45 (0·32–0·64) <0·0001

Clozapine 3 162 0·17 (0·03–0·88) 0·035

Olanzapine 12 3670 0·39 (0·30–0·51) <0·0001

Quetiapine 5 1167 0·43 (0·25–0·74) 0·002

Risperidone 21 2738 0·61 (0·52–0·72) <0·0001

Sertindole 4 1472 0·36 (0·29–0·45) <0·0001

Ziprasidone 3 501 0·50 (0·26–0·96) 0·037

Zotepine 4 398 0·59 (0·44–0·79) <0·0001

SGA versus low-potency FGA†

Amisulpride 1 30 1·00 (0·70–1·43) 1·000

Aripiprazole ·· ·· ·· ··

Clozapine 11 775 0·66 (0·48–0·91) 0·010

Olanzapine 2 152 0·53 (0·32–0·89) 0·016

Quetiapine 2 422 0·66 (0·19–2·23) 0·503

Risperidone 2 108 0·47 (0·22–0·99) 0·046

Sertindole ·· ·· ·· ··

Ziprasidone* 1 306 1·13 (0·91–1·41) 0·252

Zotepine 5 322 1·04 (0·76–1·42) 0·801

SGA=second-generation antipsychotic drug. FGA=fi rst-generation antipsychotic
drug. *Use of antiparkinsonian medication. †At least one extrapyramidal
side-eff ect.

Table 4: Extrapyramidal side-eff ects

Page 58

10539 - 07TL5223_5.eps


Articles

www.thelancet.com Vol 373 January 3, 2009 37

when the haloperidol dose was less than 7·5 mg per day;
however, a diff erence between most second-generation
antipsychotic drugs and low-potency fi rst-generation anti-
psychotics has not been shown. Most second-generation
drugs (except aripiprazole and ziprasidone) induced more
weight gain than did high-potency but not low-potency
fi rst-generation antipsychotic drugs.

Many companies claimed that improved effi cacy in
negative symptoms is a core characteristic of atypicality.22
Our meta-analysis does not confi rm this common notion
because the eff ects of some second-generation
antipsychotic drugs were not signifi cant compared with
those of fi rst-generation drugs. The most effi cacious
drugs were better in all effi cacy domains, whereas the
others ones were only as effi cacious as fi rst-generation
antipsychotic drugs, although the eff ect sizes for negative
symptoms were often larger than those for positive
symptoms. The fi ndings for depression were diff erent;
risperidone did not seem to be better than fi rst-generation
drugs, whereas aripiprazole and quetiapine were,
consistent with evidence of their eff ectiveness in major
depression.23,24 Quality of life was reported in only very
few studies; if a superiority of second-generation drugs
was noted, the eff ect size was in the same range as that
for effi cacy. In another meta-analysis, second-generation
antipsychotic drugs were better for global cognitive
functioning (eff ect size −0·24).25 Clozapine has been
shown to reduce suicidality more than does olanzapine.26

With respect to the magnitude of the effi cacy eff ect sizes,
the superiority of the more effi cacious second-generation
antipsychotic drugs was only small to medium according
to Cohen’s classifi cation.27 For perspective, the pooled
eff ect size in another review comparing second-generation
antipsychotic drugs with placebo was −0·51 and the NNT
was 6.28 Diff erences, such as higher dropout rates in the
placebo-controlled trials29 than in the active-comparator-
drug-controlled trials make it impossible for us to say that
the effi cacy of clozapine doubles the effi cacy compared
with placebo (ie, the eff ect size of antipsychotic drugs vs
placebo is 0·5128 and the eff ect size of clozapine vs
fi rst-generation antipsychotic drugs is 0·52). However,
schizophrenia usually affl icts patients for life and even a
small benefi t could be important.

In this study, second-generation antipsychotic drugs
induced fewer extrapyramidal side-eff ects than did
haloperidol, and most of them even when haloperidol
was used at doses less than 7·5 mg per day. In individual

2·0

3·0

1·0

0

–1·0

–2·0

1·0

2·0

4·0

–1·0

–2·0

–3·3

–4·0

0

4·0

5·0

6·0

7·0

kg

kg

SGA versus haloperidol

SGA versus low-potency FGA

3·0

0.5

–0·5

–1·5

1·5

2·5

4·5

5·5

6·5

3·5

2·5

3·5

1·5

–0·5

–1·5

–2·5

–3·5

0·5

SG
A

b
et

te
r

SG
A

w
or

se
SG

A
b

et
te

r
SG

A
w

or
se

Am
isu

lpr
ide

Clo
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pin
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ap
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rid
on

e

Se
rti

nd
ole

Zip
ras

ido
ne

Zo
tep

ine

Ol
an

za
pin

e

Ar
ipi

pr
az

ole

Figure 5: Weight gain
Data are mean weight-gain diff erence (kg; 95% CI). FGA=fi rst generation antipsychotic drug.
SGA=second-generation antipsychotic drug.

Number
of studies

Number of
participants

Mean weight-
gain diff erence
(kg; 95% CI)

p value

SGA versus haloperidol

Amisulpride 2 373 0·9 (0·2 to 1·6) 0·012

Aripiprazole 2 1598 0·6 (–0·1 to 1·2) 0·071

Clozapine 3 170 3·4 (2·0 to 4·9) <0·0001

Olanzapine 9 2952 3·3 (2·2 to 4·4) <0·0001

Quetiapine 3 945 1·4 (0·7 to 2·1) <0·0001

Risperidone 9 1366 1·7 (0·9 to 2·4) <0·0001

Sertindole 2 779 3·3 (0·2 to 6·4) 0·040

Ziprasidone 1 301 0·1 (–1·2 to 1·3) 0·887

Zotepine 3 321 2·7 (1·7 to 3·7) <0·0001

SGA versus low-potency FGA

Amisulpride 1 30 0·3 (–3·6 to 4·2) 0·881

Aripiprazole ·· ·· ·· ··

Clozapine 3 232 0·3 (–1·6 to 2·2) 0·753

Olanzapine ·· ·· ·· ··

Quetiapine 1 201 0·5 (–1·0 to 2·0) 0·518

Risperidone ·· ·· ·· ··

Sertindole ·· ·· ·· ··

Ziprasidone 1 307 −1·1 (–2·3 to 0·2) 0·087

Zotepine 1 106 1·0 (–0·9 to 2·9) 0·306

FGA=fi rst-generation antipsychotic drug. SGA=second-generation antipsychotic
drug.

Table 5: Weight gain

Page 114

Seminar

www.thelancet.com Vol 373 January 3, 2009 93

134 Luthje L, Unterberg-Buchwald C, Dajani D, Vollmann D,
Hasenfuss G, Andreas S. Atrial overdrive pacing in patients with
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135 Pepin JL, Defaye P, Garrigue S, Poezevara Y, Levy P. Overdrive atrial
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136 Barnes M, McEvoy RD, Banks S, et al. Effi cacy of positive airway
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137 Gotsopoulos H, Kelly JJ, Cistulli PA. Oral appliance therapy reduces
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138 Robinson GV, Smith DM, Langford BA, Davies RJ, Stradling JR.
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139 Kaneko Y, Floras JS, Usui K, et al. Cardiovascular eff ects of
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140 Mansfi eld DR, Gollogly NC, Kaye DM, Richardson M, Bergin P,
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141 Usui K, Bradley TD, Spaak J, et al. Inhibition of awake sympathetic
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142 Gilman MP, Floras JS, Usui K, Kaneko Y, Leung RS, Bradley TD.
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154 Bazzano LA, Khan Z, Reynolds K, He J. Eff ect of nocturnal nasal
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Page 115

Case Report

94 www.thelancet.com Vol 373 January 3, 2009

Lancet 2009; 373: 94

Department of Anaesthesia
and Intensive Care, Catania

University Hospital, Catania,
Italy (M Astuto MD,

C Minardi MD, G Rizzo MD,
Prof A Gullo MD)

Correspondence to:
Dr Marinella Astuto, Department

of Anaesthesia and Intensive
Care, Catania University Hospital,

Catania, Italy
[email protected]

Unexplained seizures in an infant
Marinella Astuto, Carmelo Minardi, Giuliana Rizzo, Antonino Gullo

In June, 2004, a girl was delivered by caesarean section, at
38 weeks, after the placenta became detached. When she
was 2 months old, the girl was brought to hospital with
generalised tonic-clonic seizures, tremors in arms and
legs, hypo tonia, and inconsolable crying. Blood tests,
EEG, and MRI of the head and spine showed nothing
abnormal. The girl’s mother, a housewife (the father was
a farmer) was pre scribed amitrip tyline for postnatal
depression and tension head ache; we knew of no other
family history of neuro logical illness. Concluding that the
girl had epilepsy, doctors prescribed phenobarbital; the
hypotonia was treated with physio therapy. However, in
early 2005, the girl had two further episodes of seizures.
Each time, she had serial seizures for 20 s, then cried
inconsolably for 5–7 min, and slept for 8–12 h. On
hospitalisation, she had similar episodes almost daily.
Finding the presentation inexplicable and unusual,
doctors consulted international experts, who suggested
that the girl might have a rare genetic condition, or
intermittent hemiplegia. Flunari zine was prescribed, but
stopped after 3 days, because of extrapyramidal side-
eff ects. Subsequently, the girl was admitted to hospital
around once a month, with seizures, which resolved on
treatment.

After the girl was admitted to our paediatric ward in
September, 2005, doctors witnessed a seizure lasting
20 s, and prescribed diazepam, then phenobarbital.
Electro encephalography (EEG) showed focal seizure
activity. After the seizure, doctors monitored the girl’s
EEG and electro cardiogram (ECG). Around 30 min after
the seizure, the ECG showed ventricular tachycardia,
which developed into ventricular fi brillation. The girl was
given cardio pulmonary resuscitation, and transferred to
the intensive-care department, where she was
defi brillated, and given epinephrine and lidocaine, as

well as 0∙9% saline. Sinus rhythm returned. The girl was
now haemodynamically stable; however, her Glasgow-
coma-scale score was 8. Her pupils were reactive but
dilated, and she had generalised hypotonia. We sedated
the patient with midazolam, intubated her, and ventilated
her mechanically. The next morning, the girl was
breathing independently, moving all her limbs well, and
speaking. After extubation, we told the mother that her
child was getting better. The mother did not seem
relieved; she almost insisted that the girl’s condition was
unimproved. Finding this incongruous, we requested
toxicological analysis of blood and urine samples from
the infant. Concentrations of anticonvulsant drugs were
in the therapeutic range. However, the serum concen-
tration of amitriptyline was 350 μg/L; the serum
concentration of nortriptyline (a metabolite of
amitriptyline), and the urine concentrations of amitrip-
tyline and nortryptyline, were higher than our laboratory
could quantify. We contacted the police. The mother
admitted that, since the child was 1 month old, she had
been administering amitriptyline drops to her. The child
was removed from the family home, to live with her
maternal grandmother. Sub sequently, the girl has been
seen every 3 months by a paediatrician and a neurologist.
When last seen, in July, 2008, she was well, and well
looked after.

Poisoning is one of the most common medical emer-
gencies of childhood; and tricyclic antidepressants are
frequent causes of poisoning in adults and children.1
How ever, deliberate poisoning is quite rare. We were
unable to interview the mother at length, so know little
about her motivations for poisoning the child. However,
our patient may have been a victim of factitious disorder
by proxy, also known as Munchausen’s syndrome by
proxy (panel).2,3 If our surmise is correct, the mother did
not primarily intend to kill the child. Nonetheless, she
could have done. In children, amitriptyline overdose
commonly causes seizures and tachycardia, as well as
lethargy, hyperglycaemia, and leucocytosis;4 in adults, a
serum con centration of 1000 μg/L is associated with a
high risk of death.5

References
1 Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH,

Heard SE. 2006 annual report of the American Association of
Poison Control Centers’ National Poison Data System (NPDS).
Clin Toxicol 2007; 45: 815–917.

2 Turner J, Reid S. Munchausen’s syndrome. Lancet 2002;
359: 346–49.

3 Schreier H. Munchausen by proxy defi ned. Pediatrics 2002;
110: 985–88.

4 Caksen H, Akbayram S, Odabaş D, et al. Acute amitriptyline
intoxication: an analysis of 44 children. Hum Exp Toxicol 2006;
25: 107–10.

5 Ash SR, Levy H, Akmal M, et al. Treatment of severe tricyclic
antidepressant overdose with extracorporeal sorbent detoxifi cation.
Adv Ren Replace Ther 2002; 9: 31–41.

Panel: Some psychiatric disorders that typically present as physical illness

• Factitious disorder: the patient, apparently unaware of his motives, seeks medical
attention by the intentional production or feigning of symptoms

• Munchausen’s syndrome: a type of factitious disorder, characterised by pathological
lying and peregrination

• Factitious disorder by proxy (=Munchausen’s syndrome by proxy): a caregiver,
with unmet psychological needs, seeks medical attention by fabricating or creating an
illness in a child

• Malingering: the patient knowingly fabricates a medical illness for known gain.
• Somatisation: the patient is preoccupied by physical symptoms, and believes them to

be physically caused, despite medical opinions to the contrary
• Hypochondriasis: the patient believes himself to have a serious disease, despite

medical opinions to the contrary
• Dissociative (conversion) disorder: grief or anxiety manifests as a neurological or

possession syndrome, of no neurological cause

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