674
specified in 1. The mean daily dose of mianserin was 31 (range 10-60) mg and the mean duration of the treatment was 22 (4-134) weeks. All patients were receiving doses which controlled acute symptoms of depressive episodes as continuation or prophylactic treatment; none was taking other drugs. The mean plasma mianserin concentration was 86 (54-127) nmol/l, and that of desmethylmianserin, which is pharmacologically active, was 42 (11-72) nmol/1. In 19 patients, the combined plasma concentration of these compounds was within the therapeutic range (101-183 nmol/1) that we have proposed.6 All but 1 case with mild constipation showed no anticholinergic effect during treatment. Withdrawal symptoms were evaluated by the UKU side-effect rating scale for 2 weeks after complete discontinuation of mianserin. Mianserin was withdrawn abruptly in 14 patients, and was withdrawn gradually over one month in 7. No withdrawal symptom was observed in any of these 21 patients. In the remaining 1, moderate headache was noted on the 14th day of dose reduction (from 30 to 20 mg). A 20 mg dose was continued for another 5 weeks when a similar symptom was noted on a few days. Mianserin was then discontinued, with no recurrence of headache. Gastrointestinal and general somatic distress, anxiety, and sleep disturbances have been reported with abrupt or gradual discontinuation of antidepressants.8 These withdrawal symptoms are not only distressing to patients but also complicate the pharmacotherapy of depression, since they are sometimes difficult to differentiate from relapse or recurrence of depression.8 The frequency of withdrawal symptoms for tricyclic antidepressants is high (80% for amitriptyline9 and 56% for imipramine1O). In our series headache arose in only 1 patient, who had a history of tension headache. Thus, our investigaton suggests that therapeutic doses of mianserin cause very few withdrawal symptoms. The low frequency of such symptoms might be attributable to the few anticholinergic effects of mianserin (ref 4 and present study), if symptoms do result from cholinergic overdrive, as Dilsaver and Greden have suggested. Department of Neuropsychiatry, Hirosaki University Hospital, Hirosaki 036, Japan
KOICHI OTANI HIROSHI SASA SUNAO KANEKO YUTAKA FUKUSHIMA
1. Van Dorth RM. Review of clinical studies with mianserin. Acta Psychiatr Scand 1983; 67 (suppl 302): 72-80. 2. Inman WHW. Blood disorders and suicide in patients taking mianserin or amitriptyline. Lancet 1988; ii: 90-92. 3. Coulter DM, Edwards IR. Mianserin and agranulocytosis in New Zealand. Lancet 1990; 336: 785-87. 4. Kopera H. Lack of anticholinergic and cardiovascular effects of mianserin: studies in healthy subjects and heart patients. Acta Psychiatr Scand 1983; 67 (suppl 302): 81-89. 5. Cassidy S, Henry J. Fatal toxicity of antidepressant drugs in overdose. Br Med J 1987; 295: 1021-24. 6. Otani K, Kaneko S, Sasa H, Kondo T, Fukushima Y. Is there a therapeutic window for plasma concentration of mianserin plus desmethylmianserin? Hum
Psychopharmacol (in press). Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. The UKU side effect rating scale: a new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side-effects in neuroleptic-treated patients. Acta Psychiatr Scand 1987; 76: (suppl 334). 8. Dilsaver SC, Greden JF. Antidepressant withdrawal phenomena. Biol Psychiatry 7.
1984; 19: 237-56. 9. Bialos D, Giller E, Jatlow P, Docherty J, Harkness L. Recurrence of depression after discontinuation of long-term amitriptyline treatment. Am JPsychiatry 1982; 139: 325-29. 10. Kramer JC, Klein DF, Fink M. Withdrawal symptoms following discontinuation of imipramine therapy. Am J Psychiatry 1961; 118: 549-50.
Isoelectric focusing of amniotic fluid &agr;-fetoprotein to improve diagnosis of neural tube defects SIR,-Isoelectric focusing (IEF) in the presence of 8 mol/1 urea and subsequent immunoblotting has revealed differences in the pattern of amniotic fluid Ct1-fetoprotein (AFP). This method yields more detail about the microheterogeneity of AFP than does crossed affmo-immunoelectrophoresis with concanavalin A.l2This finding might be useful in the diagnosis of open neural tube defects (NTD) and other severe fetal malformations. in IEF was done thin-layer polyacrylamide gels (230x100x0-48 mm, T=5’2%, C=3’85%) with 5%
IEF of amniotic fluid AFP.
(1)=normal pregnancy, (2)= open NTD, Arrows indicate bandsI and V.
(3) = intrauterine death
’Pharmalyte 4-6-5’ in presence of 8 moljl urea. The interelectrode distance was 9-5 cm. After prefocusing with 400 V for 20 min, 10 samples (4 ug/ml AFP) were applied 2 cm from the anode. Separation was done at fmal voltage 2500 V and a total of 3000 V h. Power was limited to 30 W. A tank blot procedure was used to transfer proteins onto (0-45 lun pore size) nitrocellulose membranes in 0-7% acetic acid at 70 V for 1 ’5 h. After blocking with 3% bovine serum albumin (BSA) in phosphate-buffered saline (PBS) for 12 h, immunoreaction was done with anti-AFP (DAKO Immunoglobulins; 1 in 500 in 1% BSA, 01% ’Tween 20’, and PBS) and swine anti-rabbit immunoglobulins conjugated with alkaline phosphatase (1in 2000) for 2 h each. The membranes were washed twice for 10 min in 0.1% tween 20 in PBS after the incubation steps. Immunostaining was done with 0-067 mglml BCIP, 0-1 mg/ml nitroblue-tetrazolium, and 3-3 mmoll magnesium chloride in 0’ 1 mol/1 diethanolamine-HCI, pH 9-6, for 10 min. The following amniotic fluid samples were analysed: 350 samples from normal pregnancies, 10 bloodstained samples with positive acetylcholinesterase but with a normal pregnancy outcome, 25 from pregnancies with open NTD, and 9 from pregnancies with intrauterine fetal death. Amniotic fluid AFP from the 13th to the 39th week of gestation from normal pregnancies shows a complex microheterogeneity with nine major bands (termed I-IX, beginning with the least acidic) and some variable minor bands (figure). The same AFP pattern was seen in all samples with a visible acetylcholinesterase band because of fetal blood contamination. However, different patterns were found in all samples from pregnancies associated with open NTD: bands I and V were much diminished or invisible. Cases of intrauterine fetal death were characterised by an increased density of band V with reduced or invisible band I. In cases of NTD and intrauterine death the acidic bands were more intense than normal. These results suggest that IEF of amniotic fluid AFP is useful for the diagnosis of open NTD, especially since it distinguishes between open NTD and specimens that are acetylcholinesterase positive for another reason. KAI WIECHEN Department of Human Genetics, HANSJORG PLENDL Klinikum der CAU Kiel, D-2300 Kiel 1, Germany WERNER GROTE 1. Hindersson P, Toftager-Larsen K, Noergaard-Pedersen B. Concanavalin A reactivity of amniotic fluid alphafetoprotein in the diagnosis of neural tube defects Lancet 1979; ii: 906. 2. Noergaard-Pedersen B, Toftager-Larsen K, Philip J, Hindersson P. Concanavalin A reactivity pattern of human amniotic fluid AFP examined by crossed affinoimmunoelectrophoresis. A definite test for neural tube defect? Chn Genet 1980, 17: 355-62.
specified in 1. The mean daily dose of mianserin was 31 (range 10-60) mg and the mean duration of the treatment was 22 (4-134) weeks. All patients were receiving doses which controlled acute symptoms of depressive episodes as continuation or prophylactic treatment; none was taking other drugs. The mean plasma mianserin concentration was 86 (54-127) nmol/l, and that of desmethylmianserin, which is pharmacologically active, was 42 (11-72) nmol/1. In 19 patients, the combined plasma concentration of these compounds was within the therapeutic range (101-183 nmol/1) that we have proposed.6 All but 1 case with mild constipation showed no anticholinergic effect during treatment. Withdrawal symptoms were evaluated by the UKU side-effect rating scale for 2 weeks after complete discontinuation of mianserin. Mianserin was withdrawn abruptly in 14 patients, and was withdrawn gradually over one month in 7. No withdrawal symptom was observed in any of these 21 patients. In the remaining 1, moderate headache was noted on the 14th day of dose reduction (from 30 to 20 mg). A 20 mg dose was continued for another 5 weeks when a similar symptom was noted on a few days. Mianserin was then discontinued, with no recurrence of headache. Gastrointestinal and general somatic distress, anxiety, and sleep disturbances have been reported with abrupt or gradual discontinuation of antidepressants.8 These withdrawal symptoms are not only distressing to patients but also complicate the pharmacotherapy of depression, since they are sometimes difficult to differentiate from relapse or recurrence of depression.8 The frequency of withdrawal symptoms for tricyclic antidepressants is high (80% for amitriptyline9 and 56% for imipramine1O). In our series headache arose in only 1 patient, who had a history of tension headache. Thus, our investigaton suggests that therapeutic doses of mianserin cause very few withdrawal symptoms. The low frequency of such symptoms might be attributable to the few anticholinergic effects of mianserin (ref 4 and present study), if symptoms do result from cholinergic overdrive, as Dilsaver and Greden have suggested. Department of Neuropsychiatry, Hirosaki University Hospital, Hirosaki 036, Japan
KOICHI OTANI HIROSHI SASA SUNAO KANEKO YUTAKA FUKUSHIMA
1. Van Dorth RM. Review of clinical studies with mianserin. Acta Psychiatr Scand 1983; 67 (suppl 302): 72-80. 2. Inman WHW. Blood disorders and suicide in patients taking mianserin or amitriptyline. Lancet 1988; ii: 90-92. 3. Coulter DM, Edwards IR. Mianserin and agranulocytosis in New Zealand. Lancet 1990; 336: 785-87. 4. Kopera H. Lack of anticholinergic and cardiovascular effects of mianserin: studies in healthy subjects and heart patients. Acta Psychiatr Scand 1983; 67 (suppl 302): 81-89. 5. Cassidy S, Henry J. Fatal toxicity of antidepressant drugs in overdose. Br Med J 1987; 295: 1021-24. 6. Otani K, Kaneko S, Sasa H, Kondo T, Fukushima Y. Is there a therapeutic window for plasma concentration of mianserin plus desmethylmianserin? Hum
Psychopharmacol (in press). Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. The UKU side effect rating scale: a new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side-effects in neuroleptic-treated patients. Acta Psychiatr Scand 1987; 76: (suppl 334). 8. Dilsaver SC, Greden JF. Antidepressant withdrawal phenomena. Biol Psychiatry 7.
1984; 19: 237-56. 9. Bialos D, Giller E, Jatlow P, Docherty J, Harkness L. Recurrence of depression after discontinuation of long-term amitriptyline treatment. Am JPsychiatry 1982; 139: 325-29. 10. Kramer JC, Klein DF, Fink M. Withdrawal symptoms following discontinuation of imipramine therapy. Am J Psychiatry 1961; 118: 549-50.
Isoelectric focusing of amniotic fluid &agr;-fetoprotein to improve diagnosis of neural tube defects SIR,-Isoelectric focusing (IEF) in the presence of 8 mol/1 urea and subsequent immunoblotting has revealed differences in the pattern of amniotic fluid Ct1-fetoprotein (AFP). This method yields more detail about the microheterogeneity of AFP than does crossed affmo-immunoelectrophoresis with concanavalin A.l2This finding might be useful in the diagnosis of open neural tube defects (NTD) and other severe fetal malformations. in IEF was done thin-layer polyacrylamide gels (230x100x0-48 mm, T=5’2%, C=3’85%) with 5%
IEF of amniotic fluid AFP.
(1)=normal pregnancy, (2)= open NTD, Arrows indicate bandsI and V.
(3) = intrauterine death
’Pharmalyte 4-6-5’ in presence of 8 moljl urea. The interelectrode distance was 9-5 cm. After prefocusing with 400 V for 20 min, 10 samples (4 ug/ml AFP) were applied 2 cm from the anode. Separation was done at fmal voltage 2500 V and a total of 3000 V h. Power was limited to 30 W. A tank blot procedure was used to transfer proteins onto (0-45 lun pore size) nitrocellulose membranes in 0-7% acetic acid at 70 V for 1 ’5 h. After blocking with 3% bovine serum albumin (BSA) in phosphate-buffered saline (PBS) for 12 h, immunoreaction was done with anti-AFP (DAKO Immunoglobulins; 1 in 500 in 1% BSA, 01% ’Tween 20’, and PBS) and swine anti-rabbit immunoglobulins conjugated with alkaline phosphatase (1in 2000) for 2 h each. The membranes were washed twice for 10 min in 0.1% tween 20 in PBS after the incubation steps. Immunostaining was done with 0-067 mglml BCIP, 0-1 mg/ml nitroblue-tetrazolium, and 3-3 mmoll magnesium chloride in 0’ 1 mol/1 diethanolamine-HCI, pH 9-6, for 10 min. The following amniotic fluid samples were analysed: 350 samples from normal pregnancies, 10 bloodstained samples with positive acetylcholinesterase but with a normal pregnancy outcome, 25 from pregnancies with open NTD, and 9 from pregnancies with intrauterine fetal death. Amniotic fluid AFP from the 13th to the 39th week of gestation from normal pregnancies shows a complex microheterogeneity with nine major bands (termed I-IX, beginning with the least acidic) and some variable minor bands (figure). The same AFP pattern was seen in all samples with a visible acetylcholinesterase band because of fetal blood contamination. However, different patterns were found in all samples from pregnancies associated with open NTD: bands I and V were much diminished or invisible. Cases of intrauterine fetal death were characterised by an increased density of band V with reduced or invisible band I. In cases of NTD and intrauterine death the acidic bands were more intense than normal. These results suggest that IEF of amniotic fluid AFP is useful for the diagnosis of open NTD, especially since it distinguishes between open NTD and specimens that are acetylcholinesterase positive for another reason. KAI WIECHEN Department of Human Genetics, HANSJORG PLENDL Klinikum der CAU Kiel, D-2300 Kiel 1, Germany WERNER GROTE 1. Hindersson P, Toftager-Larsen K, Noergaard-Pedersen B. Concanavalin A reactivity of amniotic fluid alphafetoprotein in the diagnosis of neural tube defects Lancet 1979; ii: 906. 2. Noergaard-Pedersen B, Toftager-Larsen K, Philip J, Hindersson P. Concanavalin A reactivity pattern of human amniotic fluid AFP examined by crossed affinoimmunoelectrophoresis. A definite test for neural tube defect? Chn Genet 1980, 17: 355-62.
