Violent Behavior among hospitalized medical and surgical patients

To characterize violent behavior in hospitalized medical and surgical patients, we reviewed documented violent incidents at the San Francisco General Hospital during a two-year period. Twenty-nine incidents of verbal and physical violence occurred. One patient was gravely ill and three were delirious. All the incidents were associated with increased levels of tension and loss of impulse control. In most cases, contention with the staff regarding pain medication or ward regulations was a precipitating event. Of the 28 patients with mental disorders, 19 were substance abusers, six had organic brain syndrome, tw had neurosis, and one had schizophrenia. The findings suggest that physicians should be more sensitive to patient characteristics and to the situational characteristics of the violent incident. Explicit measures that anticipate and reduce violent behavior are reviewed.     

Variants of psychosomatic personality development in diseases of the gastrointestinal tract

612 patients with different psychosomatic disorders of gastrointestinal tract (GIT) were examined. They included either 200 patients with organic stomach disease or with duodenal ulcer as well as 412 individuals with various functional disorders of GIT such as psychogenic vomiting, dysphagia, gastralgia and colon irritability syndrome. In 70% of all cases patientc relatives (1-3 degree of relationship) had also some psychosomatic diseases. All the patients suffered in childhood from so-called GIT-variant of children's neuropathia. Being adults they all met intensive or moderate stress and developed psychogenic depression. Two ways of psychosomatic disorders cristallization on the background of depression were observed, exactly reactivation of children's neuropathia symptomes or rapid affect somatization which were followed by psychosomatic cycles formation and by stress tolerance decrease. Several types of psychosomatic development were described: hypochondrial (78.8%), asthenic (12.4%), obsessive (2.3%), hysterical (4.4%) and paranoial (2.1%).     

Dissociative stupor--differential diagnosis of coma following injury

Two cases are described in which a dissociative stupor originating from conversion neurosis simulated a coma following a sustained trauma. At first both patients showed no response to being addressed or to pain stimuli. They presented an upward eye gaze deviation, cardiorespiratory functions were stable. Following extensive diagnostic procedures revealing no organic cause for the clinical symptoms, the diagnosis of a hysterical consciousness disorder was stated. Symptoms of conversion neuroses include lacking call response, gait disorder, seizure-like conditions and strength diminution in one or more extremities. In these cases suspicious facts are the absence of injuries (for example by falling down or tongue bite during a dissociative attack), eye gaze deviation and the phenomenon that, when the patient's arm is raised above the head and let fall, it never hits the face but glides down beside the body.     

Endogenous adenosine attenuates long-term depression and depotentiation in the CA1 region of the rat hippocampus

We describe a series of 144 cases of leptospirosis diagnosed in 1989 in New Caledonia. The incidence rate was 90 per 100,000 person-years, with a specific mortality rate of 4% patients. Those affected (100 males, 44 females) were mainly aged 20 to 40 years. Incidence in rural areas (112 per 100,000 person-years) was seven times higher than in urban settlements. Two periods with higher incidence were noticed corresponding to highest rainfall. Twenty-nine of the cases occurred in individuals with professions commonly associated with leptospirosis. Contacts with rats, dogs and ditch or river water were the most frequently mentioned. The clinical expression of the disease was polymorphic: 60% of the patients had mild symptoms, 40% were acute forms including Weil's disease. Of 57 hospitalized, 23% were admitted with an initial diagnosis of dengue, and 37% with leptospirosis. Main clinical syndromes were: icterus and/or renal syndrome in 50% of patients, cardiac syndrome in 65%, acute myalgies in 58% and pulmonary syndrome in 50%. Although hemorrhages were uncommon (17%), 40% of the cases demonstrated thrombocytopenia (< 50,000/m3). Pancreatic involvement with hyperamylasemia was evidenced in 50% of cases. Twelve serogroups of Leptospira were implicated, Icterohaemorragiae predominated (41%), but was not associated with severe forms. In New Caledonia, like in all tropics, leptospirosis must be considered as an environmental diseases, professional activities being just an additional risk factor. Use of serology as a reliable tool for confirmation of cases in areas of high environmental contamination is discussed.     

Mental disorders in a pediatric clinic

In general pediatric clinic 262 children aged 1-15 years with functional hyperthermia, functional disorders of cardiac rhythm (extrasystole, paroxysmal and recurrent tachycardia), arterial hyper- and hypotension, autonomic dysfunctions were examined. 21 children with organic cardiac diseases were examined too. Mental disorders were revealed in all the cases: mono- and bipolar affective disorders (58.1%) as well as affective-dilutional (10.4%) states, primarily in the form of "masked" hypomanias, neurotic and neurotic-like (16.2%), psychopathic and psychopathic-like (7.0%), psychoorganic (3.7%) and epileptiform (4.6%) syndromes. The spectrum of mental disorders was extremely wide--from practical normal (in limits of reactions of personal accentuations or age crisis) to endogenic diseases. Combined treatment including drug therapy, psychotherapy and family correction was quite effective.     

Incidence and clinical epidemiology of necrobacillosis, including Lemierre's syndrome, in Denmark 1990-1995

To establish the incidence and describe the clinical epidemiology of necrobacillosis and Lemierre's syndrome in Denmark, the clinical records of all laboratory-recorded cases of septicaemia due to Fusobacterium necrophorum biovar A, B, and C were reviewed retrospectively during a 6-year period. The incidence of necrobacillosis and Lemierre's syndrome was 1.5 and 0.8 per million persons per year, respectively, showing a tendency to increase during the period. Fusobacterium necrophorum was grown after three days' incubation, but the characteristic pleomorphic fusiform morphology was often disregarded as an important help in diagnosing necrobacillosis. The 24 patients with Lemierre's syndrome were all young and previously healthy, and none died, but pre-hospital delay was associated with a significantly higher morbidity and risk of metastatic infections. The remaining 25 patients with necrobacillosis had a high mortality, 24%, which was correlated with age and predisposing diseases, especially cancers. These findings stress the importance of a quicker clinical and microbiological diagnosis in cases of Lemierre's syndrome, and of screening for cancer in the remaining cases of necrobacillosis.     

Family studies and human leukocyte antigen class II typing in Indian probands with seizures in association with single small enhancing computed tomography lesions

PURPOSE: To define the clinical features of the syndrome of seizures associated with single, small, enhancing computed tomography (CT) lesions (SSELs) in 235 Indian probands and seizure types among their family members. Human leukocyte antigen (HLA) class II genomic typing in randomly selected 41 probands was done to identify the role of hereditary factors in this syndrome. METHODS: The seizure types among 235 probands, their clinical outcome, and seizures in their family members were studied. Family data were collected on relatives of 212 additional probands with neurologic diseases other than epilepsy. HLA class II antigens were studied by using polymerase chain reaction (PCR) amplified DNA and sequence-specific oligonucleotide probe (PCR-SSOP) hybridization. RESULTS: The seizures in 86% were partial with or without generalization; 77% had fewer than five seizures before the first CT scan. Evanescent focal neurologic deficits after seizures were noted in 40%. Most patients (97%) were treated with a single antiepileptic drug (AED). Significant resolution of the CT scan lesion was noted within 6 months in 125 (53%) of 235 cases. Two thirds of patients had no seizures while taking a single AED, and an additional 18% had no seizures even after their AEDs were discontinued. Epilepsy among relatives of Indian probands having seizures in association with SSELs was more common as compared with relatives of probands with other neurologic diseases. A family history of seizures was noted in 21% probands, the ratio of affected first- to second-degree relatives was 4.3:1, and 60% of affected sibs had syndromic concordance with probands. There was a positive association of HLA-DRB1*13 (Pc = 0.036) with this syndrome. CONCLUSIONS: The syndrome of seizures in association with SSELs seems to be a benign localization-related epileptic syndrome. Our results of HLA studies point to an inherited susceptibility to an infective agent, which in most cases is of cysticercal etiology.     

Effects of aging, organicity, alcoholism, and functional psychopathology on WAIS subtest profiles.

Used multivariate ANOVA to examine the independent effects of several factors (age, diagnosis, sex, race, and socioeconomic status) on WAIS subtest patterns. A total of 414 psychiatric patients were studied, including 29 with organic brain syndrome and 29 alcoholics. A discriminant function contrasting organic brain syndromes with lesser functional psychiatric disorders was defined. Alcoholic patients were found to occupy a position close to the organic brain syndrome group on that continuum. Aging was associated with deficits in specific subtests, whereas the organic brain syndrome pattern involved more generalized deficits. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conservative functional therapy of closed rupture of the Achilles tendon. Treatment approach and analysis of results

In a prospective study in the period from May 1989 to April 1994, 161 patients at the Unfallchirurgische Klinik in Braunschweig were treated for rupture of the Achilles tendon using a conservative functional method. A follow-up examination was carried out on 132 patients (81%) after an average of 12.6 months. Conservative therapy was indicated if dynamic ultrasonography showed sufficient adaptation of the rupture. Continuous retention of the adapted tendon fragments was guaranteed by means of special footwear that raises the back of the foot (Variostabil). The average age of the patients was 39.5 years. In 97 cases (73.5%) the injury was caused by sports. In 68 ruptures the dehiscence was compensated in plantar flexion. In 48 cases the dehiscence was 1-5 mm, and in 16 cases it was between 6 and 10 mm. The average period of hospitalization was 4.8 days (1/19). The period of inability to work was an average of 4 weeks (27.4 days (0/98)). The rupture healed on an average of 9.5 weeks (5.9/23). Complications included seven cases of re-rupture (5.3%), and, in the course of treatment, four patients (3%) suffered profound leg vein thrombosis that in one case developed into postthrombotic syndrome. In two cases there was tendovaginitis of the Achilles tendon. Early functional conservative therapy using the VARIO-STABIL shoe is a suitable method for treating a newly ruptured Achilles tendon. When there is a precise indication, the method is equally as good as operative therapy and because of the low complication rate, it is even preferable.     

The relationship of current psychiatric disorder to functional disability and distress in patients with inflammatory bowel disease

Although prior theories about psychiatric disorders causing inflammatory bowel disease (IBD) have largely been discredited, these same disorders have at times been associated with functional gastrointestinal symptoms such as those found in irritable bowel syndrome. Since functional gastrointestinal symptoms can also occur in patients with organic pathology, we hypothesized that a current psychiatric disorder might amplify or produce additional gastrointestinal symptoms in patients with organic gastrointestinal diseases such as IBD, leading to additive functional disability and decreased quality of life. This pilot study evaluated a sequential sample of 40 IBD patients using the NIMH Diagnostic Interview Schedule, structured interviews for functional gastrointestinal symptoms, and prior episodes of emotional, physical, and sexual abuse as well as self-report measures of personality and disability. We compared IBD patients with and without a current psychiatric disorder while controlling for disease severity. Eight patients with major depression were treated with antidepressants. Patients with a current psychiatric disorder had significantly higher 1) mean number of lifetime psychiatric diagnoses, 2) prevalence rates of prior sexual and physical victimization, and, 3) mean numbers of both gastrointestinal and other medically unexplained symptoms despite no differences in severity of IBD. Significant and trend level differences were apparent on several measures of functional disability. A regression analysis showed that number of psychiatric diagnoses, number of functional gastrointestinal symptoms, and dissociation scale scores significantly discriminated the groups. Treatment of current major depression decreased functional disability despite no objective changes in gastrointestinal disease severity. It was concluded that the presence of a current psychiatric disorder appears to alter the perception of disease severity in patients with IBD. Nonrecognition of the psychiatric disorder may lead to unnecessary and aggressive interventions for IBD patients such as medication changes, invasive testing, or surgery. The presence of a current psychiatric illness also appears to be associated with increased functional disability. Psychiatric evaluation and treatment, therefore, have an important role in the ongoing management of IBD patients with distressing gastrointestinal symptoms not directly attributable to their IBD.     

Alveolar soft-part sarcoma: further evidence by FISH for the involvement of chromosome band 17q25

BACKGROUND/PURPOSE: Down's syndrome is a common association in patients with anorectal malformations. The purpose of this study was to determine whether the anorectal defect in patients with Down's syndrome had specific characteristics and whether the presence of Down's syndrome represented a serious detriment to the patient's functional prognosis. METHODS: Nine hundred eighty-seven patients with anorectal malformations were studied retrospectively. Twenty patients (2%) had Down's syndrome. Nineteen of these (95%) had the same specific type of anorectal defect: imperforate anus with no fistula. This defect has a good prognosis, the rectum is located about 2 cm above the perineal skin, the sacrum is normal, and the sphincter mechanism is good. For comparison, a group of 34 patients with the same defect but without Down's syndrome was also studied. All patients were operated on via posterior sagittal approach by the same surgeon. RESULTS: Imperforate anus without fistula occurs in 5% of all patients with anorectal malformations and in 95% of those patients who also suffer from Down's syndrome. The characteristics of the defect were the same in both groups of patients, and surprisingly, the prognosis was good in both groups (80% to 96% of patients had voluntary bowel movement, 100% had urinary continence). CONCLUSIONS: The association of Down's syndrome with imperforate anus without fistula is not coincidental. This particular benign defect can be predicted to occur in most patients with Down's syndrome. The presence of Down's syndrome in cases of anorectal malformations should not be a contraindication to repairing the imperforate anus and to closing the colostomy.     

Clinical review of 74 cases with miliary tuberculosis

Seventy-four cases of miliary tuberculosis were studied retrospectively. The mean age of the patients was 45.3 years. Twenty-two patients suffered from another underlying diseases. Six were infected with human immunodeficiency virus. Twelve had been treated with corticosteroids. Fever was present in 97.3 per cent of patients. Elevation of serum alkaline phosphatase was found in 67.6 per cent of cases. The skin reaction to tuberculin was positive in 61.2 per cent. Nodular shadows were found in the chest X-ray in 98.6 per cent of cases. The nodules were smaller than 2 mm in diameter in 52.7 per cent of cases. Other findings were enlargement of mediastinal lymph node (17.6%), cavities (23.0%), pleural effusion (27.0%), and consolidation (35.1%). Sputum cultures and urine cultures were positive for Mycobacterium tuberculosis in 76.8 per cent and 58.6 per cent of cases respectively. The diagnosis was confirmed by histopathological findings in some cases. The rate of positive biopsies was 61.5 per cent by bone marrow aspiration, 83.3 per cent by lymph node biopsy, 100 per cent by liver and lung biopsy. Antituberculosis therapy was successful in most of the patients. Seven patients died of miliary tuberculosis, 4 of them had adult respiratory distress syndrome.     

Simultaneous presentation of autoimmune thyroiditis and celiac disease in an adult

Celiac disease may be associated with other underlying autoimmune diseases. Among these, thyroid disease has been described in around 10% of the cases with hypothyroidism being the most frequently reported. Clinical suspicion of thyroid involvement in patients with celiac disease is difficult since the symptomatology is scarce or is masked by the picture of malabsorption. Nonetheless, its detection is important since it is not solved by gluten free diet and its correction requires specific treatment. Thyroid function studies, in addition to determination of antithyroglobulin and antimicrosomal antibodies, should be considered in celiac patients refractory to conventional dietetic treatment. We herein present the case of a 65-year-old woman who consulted for a malabsorption syndrome in whom celiac disease of the adult was simultaneously presented with hyperthyroidism secondary to autoimmune thyroiditis.     

Role of radiologic diagnosis in rectal mucosal prolapse

Defecography (DG) is a useful method to detect many morpho-functional deformities of anus and rectum and pelvic floor. We report on a clinical and radiologic study of 165 patients (36 men and 129 women) suffering from defecation disorders and rectal muscosal prolapse (RMP). All the patients had been submitted to clinical examination, endoscopy and double contrast enema to rule out organic colorectal conditions. DG was performed with a dedicated conmode and high-density barium and videorecorded on VHS cassettes to assess the dynamics of evacuation phases and to reduce exposure doses. DG showed single RMP in 28% of cases and multiple RMP in 72% of cases; the condition was isolated in 22% of cases, while in 88% of cases it was associated with other anorectal dysfunctions, such as rectocele (65%), perineal descent syndrome (PDS) (15%), puborectal muscle syndrome (14%) and intussusception (8%). RMP appeared at DG as a wall defect bulging into rectal lumen, which was more evident under straining and during barium evacuation. In 12 patients with multiple RMP, dynamic CT of the pelvis was carried out to study the whole pelvic floor and in 5 cases it showed levator ani diastasis. Fifty-eight patients were submitted to surgery by elastic binding of RMP; DG follow-up showed RMP remission in 47 patients, single RMP relapse in 3 patients and multiple RMP relapse in 3 patients. One patient with PDS and intussusception was submitted to rectopexy and mucosectom.     

Diagnostic difficulties of myocardial infarct in an admissions and emergency service: influence of age

OBJECTIVE: To analyze the clinical signs and electrocardiographic and enzyme data in patients admitted to an emergency ward for myocardial infarction in order to highlight diagnostic pitfalls. PATIENTS AND METHODS: All patients admitted to our emergency ward between October 1995 and October 1996 with elevated myoglobulin or creatinine phosphokinase (CPK) levels (n = 457 patients) were included in the study series. Patient files were randomly selected (n = 257 files) for review by an emergency ward specialist and a cardiologist to identify cases of myocardial infarction (n = 88 patients, mean age 73.4 +/- 15.2 years). Clinical, electrical and enzyme data (including CPK-MB) were analyzed. RESULTS: The patients had been referred for chest pain (69%), dyspnea (24%) or another disorder (7%). Pain was located in the retrosternal area in 51%, in the lower chest in 19% and elsewhere in 30%. Delay between onset of pain and transfer to the emergency ward was 5 h 20 min +/- 6 h. Signs of left heart failure were observed in 50% of the patients. The admission electrocardiogram showed complete criteria for myocardial infarction in 43% of the cases, incomplete criteria in 21% and was non-contributive in 36%. Enzyme results were elevated in 78% of the cases at the first assay and in 98.2% at the second assay. Both typical chest pain and ECG were observed in only 30% of the cases. Chest pain was present in 55% of the patients over 75 years of age and in 81% of those under 75 years (p = 0.007). CONCLUSION: A typical syndrome is observed in less than one-third of all patients with myocardial infarction admitted to emergency wards. The frequency of atypical presentations increases with age.     

Clinical and electrophysiological findings and follow-up in tarsal tunnel syndrome

The authors report clinical and electrophysiological findings in 59 patients with tarsal tunnel syndrome (TTS) and follow-up in 23 of them. The entrapment was prevalent in females; was bilateral in 6 patients and involved medial plantar in 7 and lateral plantar nerves in two cases. Eleven presented with other nerve entrapment syndromes or focal mononeuropathies, due to hereditary neuropathy with liability to pressure palsy or systemic diseases. The other 48 subjects had TTS without any other related entrapment syndromes: 23 were idiopathic cases, 13 had a history of local trauma, 3 had systemic diseases and the others had external or intrinsic compressions. The most frequent symptoms were paraesthesia or dysaesthesia (86% of feet) and pain (55%). Hypoaesthesia of the sole and weakness of toe flexion were evident in 74% and 22% of feet, respectively. Absence of sensory action potential or slowing of sensory conduction velocity (SCV) of the plantar nerves were present in 77% of feet; significant differences of SCV between affected and unaffected plantar nerves and/or between distal sural and plantar nerves were evident in 14%. Abnormalities of plantar SCV were therefore absent in only 9% of feet. Distal motor latency was delayed in 55% and electromyography showed neurogenic changes in 45% of sole muscles. Five cases (6 feet) underwent surgery with excellent or good results in 5, 4 of them also showing improvement in distal conduction of the plantar nerves. Nine were treated with local steroid injections, with good results shown in 6 patients. Nine other patients who did not receive any therapy showed a disappearance of symptoms or good outcome in 6 cases. The subjects with poor therapeutic results had S1 radiculopathy or systemic diseases. The authors underline that patients with connective tissue diseases should not be treated by surgical decompression because they may have subclinical neuropathy. Some subjects with idiopathic or trauma-induced TTS recover spontaneously. Surgical release should be limited to cases with space-occupying lesions and when conservative treatments fail.     

Tubular apocrine adenoma

Two cases of Gilbert's syndrome and three cases of other diseases showed abnormally low plasma indocyanine green (ICG) clearance as contrated with normal or nearly normal plasma sulfobromphthalein (BSP) clearance. To evaluate the role of serum proteins in pathogenesis of these cases, ICG-binding patterns of serum proteins of the patients were compared with that of normal persons by the method of Sephadex G200 column chromatography. No qualitative differences in binding patterns were observed between serum proteins of the patients and normal persons. From these results, serum proteins were thought to be minor determinants of the hepatic ICG uptake mechanism. Because of normal or nearly normal plasma BSP clearance in these patients, the contents of hepatic organic anion-binding proteins, Y and Z, were thought to be sufficient. Possible qualitative abnormalities of the Y and/or Z proteins were also discussed.     

Weighing the risks and benefits of an oral cancer screening

The study into the causes underlying nonspecific lymphadenitis (NSL) and adenophlegmons of the maxillofacial region and the neck (AF) revealed a great variety of etiological factors and primary infectious foci in these diseases. Of 204 children admitted to hospital of the city of Derbent, odontogenic genesis of the disease was determined in 27.45% of cases; dermatogenic, stomatogenic in 23.04 and 12.74% of cases, respectively. ENT and systemic diseases were responsible for NSL and AF in 13.23 and 3.43% of cases. The cause remained unclear in 20.09% of patients. NSL and AF occurred most frequently in the coldest (January, February) and the hottest (July, August) months of the year.