A comparison of descriptive characteristics of male outpatients and inpatients with affective disorders

Recent studies of patients with affective disorders have found that there are biological differences between inpatients and outpatients. Concerned by these findings, we compared individuals admitted to our inpatient and outpatient affective disorders clinical research center who met criteria for major depression. We hypothesized that inpatients would be more severely ill, more suicidal, more functionally impaired, and have more co-morbid disorders and higher ratings of depression and mood state dysfunction. The demographic profiles, lifetime co-morbid Axis I diagnoses, consumption histories, symptom profiles, global assessment of functioning, and severity of current stressors (Axis IV) were compared and contrasted for the two groups. Inpatients had more severe current psychosocial stressors, lower current levels of functioning, increased lifetime co-morbid Axis I diagnoses, and increased rates of psychiatric hospitalizations, however, they did not have higher depression symptom ratings. In conclusion, inpatients and outpatients differed significantly in the severity of their stressors, coping abilities and history of previous hospitalizations, but not in most demographic variables or their current symptoms of depression.     

Computerized axial transverse tomography in cerebrovascular disease

One hundred eleven patients with supratentorial cerebrovascular disease were studied by computerized axial tomography (CT scanning). With one exception, every patient who had a normal scan 48 hours after the onset of symptoms was ultimately diagnosed as having had transient ischemic attack, although in nearly one-third, the clinical diagnoses at the time of the scan was infarction. A normal CT scan, therefore, augurs a good outcome of supratentorial cerebrovascular disease. Ninety-eight percent of the patients with infarction had abnormal scans, with areas of decreased density in a vascular distribution. Pitfalls in the diagnosis of infarction were (1) initially normal CT scans that changed to abnormal after 48 hours, and (2) mass effect of infarction leading to misdiagnosis of brain tumor. Serial studies eliminated both pitfalls. Intracerebral hemorrhages had a distinctive high density appearance. In 43 percent of patients whose scans showed hemorrhage, the clinical diagnosis was thrombosis. Many did not have symptoms, signs, or outcome of cerebral hemorrhage, and the diagnosis would not have been suspect were it not for the CT scan.     

Biliary dyskinesia: natural history and surgical results

Patients with biliary dyskinesia have symptoms consistent with biliary colic and an abnormal gallbladder ejection fraction (GEF) in the absence of cholelithiasis. Cholecystokinin hepatobiliary scan quantifies gallbladder function and may assist in selecting patients with acalculous biliary pain who would benefit from cholecystectomy. Seventy-eight patients with an abnormal GEF (< 35%) on cholecystokinin hepatobiliary scan without cholelithiasis were studied retrospectively. Patients were divided into groups based on diagnosis and treatment. In Group I, the patients who underwent cholecystectomy, 80 per cent (35 of 44) had complete symptomatic resolution whereas the remaining 20 per cent (9 of 44) had symptomatic improvement. Pathology reports demonstrated chronic cholecystitis in 95 per cent of specimens. Group II were patients with symptoms attributable to biliary dyskinesia, but did not undergo cholecystectomy. Persistence of symptoms was noted in 75 per cent (18 of 24) of patients whereas 25 per cent (6 of 24) had symptomatic resolution without any treatment. Group III consisted of patients with an abnormal ejection fraction who had improvement of symptoms after treatment for an alternative diagnosis (n = 10). These findings suggest that an abnormal ejection fraction does not always indicate gallbladder disease. Alternative diagnoses must be investigated and treated. Patients with persistent biliary type symptoms in combination with an abnormal GEF in the absence of other attributable causes can expect a favorable response to cholecystectomy.     

Evaluation of an immunohistochemical test with polyclonal antibodies raised against mycobacteria used in formalin-fixed tissue compared with mycobacterial specific culture

OBJECTIVES: In neurogenic dysphagia a good cough is important for airway protection. If triggering of cough, or its effectiveness, is impaired this might result in an increased aspiration risk. Capsaicin, an agent which induces cough through sensory nerve stimulation, was used to test cough sensitivity in groups of patients with and without neurogenic dysphagia. METHODS: On the basis of swallowing speed (ml/s) in a validated water test 28 alert neurological inpatients (16 women, aged 22-71 years) were classified into 13 with abnormal and 15 with normal swallowing (median swallowing speed 23% and 99%, median volume/swallow 43% and 106% of that predicted for age and sex respectively: p<0.001). Capsaicin nebulised on air in saline was inhaled via a low resistance valve using a mouthpiece and noseclip. Up to seven incremental concentrations of capsaicin ranging from 0.07-20.0 x 10(-4) mol/l were each inhaled for up to a minute. A pneumotachograph connected to the expiratory limb gave a paper recording of expiratory air flow. Coughs were recorded as high flow expirations of short duration. Capsaicin concentrations at first cough (threshold) were recorded; concentrations at frequencies of 10 and 20 coughs/minute were interpolated from the dose-response curve. RESULTS: Cough threshold tended to be lower in those with abnormal swallowing (non-significant): the (log) concentration of capsaicin producing 10 or 20 coughs/ minute also tended to be lower (p=0.12 and 0.07 respectively) in those with abnormal swallowing. CONCLUSION: Contrary to expectation, these results suggest that cough responsiveness is enhanced in alert patients with neurogenic dysphagia even after allowing for diagnostic category, the possible presence of a bulbar upper motor neuron lesion, or voluntary respiratory capacity. It is concluded that these patients with neurogenic dysphagia do not have a reduced sensitivity of cough triggering.     

Serum S-100 protein: a potentially useful prognostic marker in cutaneous melanoma

BACKGROUND: A 360 degrees or Nissen fundoplication remains controversial in patients with disordered peristalsis, some surgeons preferring a partial wrap to minimise postoperative dysphagia. AIM: To evaluate symptoms and manometric outcome in patients with disordered peristalsis after Nissen fundoplication. PATIENTS: In an initial series of 345 patients studied prospectively, 31 patients who had undergone a Nissen fundoplication had disordered peristalsis. Using preoperative manometry, patients were classified as: equivocal primary peristalsis (eight patients); abnormal primary peristalsis (four patients); abnormal maximal contraction pressure (13 patients); abnormal primary peristalsis and maximal contraction pressure (six patients). METHODS: Postoperatively, patients underwent a barium meal, oesophageal manometry and standardised clinical review by a blinded scientific officer. RESULTS: Twenty eight (90%) patients had satisfaction scores of at least 8 out of a maximum of 10 and all would undergo surgery again. Whereas 15 (48%) patients had dysphagia scores greater than 4/10 preoperatively, only two (6%) had these scores at one year. Improved peristalsis was seen in 78% of postoperative manometric studies, and mean preoperative lower oesophageal sphincter pressure increased from 6.6 (range 0-21) mm Hg to 19 (4-50) mm Hg. CONCLUSIONS: These results are similar to the overall group of 345 patients and suggest that disordered peristalsis, and possibly even absent peristalsis, is not a contraindication to Nissen fundoplication as performed in these patients.     

Timing and side effects of flumazenil for dental outpatients receiving intravenous sedation with midazolam

We studied the timing and side effects of flumazenil treatment for 10 healthy volunteers and 46 dental outpatients who received intravenous sedation with midazolam. For the volunteers, vital signs were monitored before and after intravenous injection of midazolam and flumazenil. In addition, grip strength, signs and symptoms, and performance on the Romberg's test and addition tests were evaluated 30 min and 60 min after midazolam injection as well as after flumazenil injection. There were no significant changes in vital signs before, immediately after, or 50 min after injection of flumazenil, the latter time corresponding to the half-life of the drug. Thus, awakening from sedation was associated with no effects on the cardiovascular or respiratory systems. Distinct effects of flumazenil were demonstrated by the Romberg's test and the assessment of sedation status. Flumazenil had no effect on the outcome of the addition test. For the outpatients, sedation status and signs and symptoms were studied in patients undergoing procedures lasting 30 min or less (group S) and those undergoing procedures lasting 31 to 60 min (group L). Three patients in group S and one in group L had signs and symptoms of resedation. After treatment with flumazenil, abnormalities such as excitability and nausea were reported by only two patients in group L. One patient in group S had drowsiness that did not resolve after injection of flumazenil and continued until the following day. Our results indicate that flumazenil should be given at least 60 min after intravenous sedation with midazolam in dental outpatients. Moreover, caution should be exercised with regard to the potential side effects of flumazenil.     

A preliminary study of clarithromycin versus doxycycline in the treatment of nongonococcal urethritis and mucopurulent cervicitis

In a comparison of drug safety and efficacy, 40 adult outpatients with clinical signs and symptoms of nongonococcal urethritis or mucopurulent cervicitis were treated with either clarithromycin 250 mg or doxycycline 100 mg twice/day for 7 days. Clinical and laboratory evaluations were repeated during, at the end, and 3 weeks after the completion of therapy. Isolation and susceptibility tests of Chlamydia and Mycoplasma isolates were performed at each visit. All but one patient who received doxycycline were clinically cured or improved at the end of treatment. Two (10%) patients who received clarithromycin and three (15%) who received doxycycline had clinical relapses of the infection. All isolates of Chlamydia trachomatis were eradicated and did not recur in both groups. Doxycycline was more effective than clarithromycin in eradicating Ureaplasma urealyticum (p < 0.01). Both groups reported a high frequency of minor adverse effects, but no patient discontinued therapy. Overall, clarithromycin was clinically safe and effective treatment in patients with nongonococcal urethritis and mucopurulent cervicitis.     

The reliability of cysto-urethrographic signs in the diagnosis of detrusor instability in children

OBJECTIVE: To assess whether the signs associated with detrusor instability (DI), as assessed by video-urodynamic studies, can be evaluated by conventional voiding cysto-urethrography (VCUG). PATIENTS AND METHODS: Fifty-nine children who underwent cystometry and VCUG were reviewed and divided into two groups; group 1 comprised 51 neurologically normal children who had DI (47 girls and four boys, mean age 7.9 years, range 4-14), with no malformations or previous surgery. Most had mixed symptoms, including urinary tract infections (44) and nocturnal enuresis with daytime symptoms (20); group 2 (control) comprised eight children (seven girls, mean age 9.7 years, range 6-15) with a stable bladder and the same clinical presentation. The interval between VCUG and cystometry ranged from 1 day to 5 months (mean 47 days) and was similar in both groups. Signs considered suspicious of DI were sought in the findings of VCUG. RESULTS: In group 1, VCUG was normal or showed no specific signs (only vesico-ureteric reflux or vaginal voiding) in 25 (49%) of patients, whereas 26 (51%) had some signs suspicious of DI. Suspicious signs were urethral ballooning (in 11), bladder trabeculation or a constricting ring (eight), a 'spinning-top' urethra (three), urethral notching (two) and Mercier's bar (one). In group 2, five patients had no abnormal findings on VCUG and three had suspicious signs. The positive predictive value of VCUG was high (0.89) but the diagnostic yield of suspicious signs was low, because the sensitivity (0.5), specificity (0.62) and overall accuracy (0.52) were low. CONCLUSION: Radiological signs suspicious of DI cannot be regarded as such in conventional VCUG, as although they were detected in half the patients with DI, they also occurred in three of eight children with a stable bladder.     

Usefulness of simple endoscopic aspiration cytology of pancreatic juice for diagnosis of early pancreatic neoplasm. A prospective study

For detection of early cancer of the pancreas, endoscopic aspiration cytology of pancreatic juice without endoscopic retrograde pancreatography was performed in 64 consecutive outpatients who had symptoms or findings that suggested pancreatic disease. Patients with positive or suspicious cytologic results or abnormal US findings were admitted and underwent detailed examinations. Positive and suspicious cytologic results were obtained in 2 and 10 patients, respectively. Of those with positive and suspicious cytologic results, two, and one patient, respectively, were ultimately found to have pancreatic neoplasms. Of these three resected specimens, one was in situ carcinoma and two presented marked atypia. All patients were alive with no evidence of recurrence. No further cases of pancreatic neoplasm were found. Complications from the procedure did not develop in any patient. This technique is useful in the diagnosis of early neoplasms of the pancreas, because it is simple and safe to perform for outpatients.     

The utility of chest radiography in the follow-up of pneumonia

AIM: We conducted this study to determine whether chest radiography was clinically useful in the follow-up of uncomplicated pneumonia affecting children aged between 6 weeks and 15 years. METHOD: We examined the case records of all 78 paediatric admissions for pneumonia to our hospital over one year. Thirteen children were excluded on account of age or other complicating factors. RESULTS: Of the 65 study cases, the mean age was 3.5 years (range 0.4-13 years). On admission 51 (79%) had cough, 53 (82%) fever, 53 (82%) tachypnoea and 50 (77%) had abnormal chest signs. Elevation of C reactive protein was recorded in 43 (66%) cases and leukocytosis in 42 (65%). All children received initial chest radiographs which showed unilobular/lobar changes in 34 (53%), bilobar changes in 19 (29%) and diffuse abnormalities in 7 (11%). Forty-one patients were followed up both clinically and radiologically, usually (31 cases) between four and six weeks after discharge. Thirty-seven children had no abnormal symptoms or signs and had normal chest radiographs. The remaining four had symptoms and signs, their radiographs showed either slight resolution or no change from the admission films. CONCLUSION: In cases of uncomplicated pneumonia, follow-up chest radiography should be deferred until at least four weeks after discharge and is not indicated if symptoms and signs are absent.     

Higher environmental temperature potentiates cataleptic effect of fentanyl in rats

OBJECTIVE: The aim of this study is to review research examining an immunological basis for chronic fatigue syndrome (CFS) and to discuss how a disturbance in immunity could produce central nervous system (CNS)-mediated symptoms. METHOD: Data relevant to the hypothesis that abnormal cytokine release plays a role in the pathogenesis of CFS are reviewed as well as recent evidence relating to potential mechanisms by which immune products may enter the brain and produce a disturbance in CNS processes. RESULTS: Examinations of cytokine levels in patients with CFS have produced inconclusive results. Recent evidence suggests that abnormal release of cytokines within the CNS may cause neural dysfunction by a variety of complex mechanisms. CONCLUSION: Neuropsychiatric symptoms in patients with CFS may be more closely related to disordered cytokine production by glial cells within the CNS than to circulating cytokines. This possibility is discussed in the context of unresolved issues in the pathogenesis of CFS.     

Disequilibrium in patients with atherosclerosis: relevance of pontine ischemic rarefaction. Amsterdam Vascular Medicine Group

OBJECTIVE: To examine the clinical relevance of isolated pontine hyperintense lesions (PHLs) on MRI in patients with atherosclerosis. METHODS: Seventeen atherosclerotic patients with isolated PHL on MRI were compared with 17 patients without PHL and were matched for age, sex, and initial manifestation of atherosclerosis. Subjects and observer were blinded to the MRI findings. We assessed symptoms, impairment, and disability with a structured interview and neurologic examination as well as disability scales. RESULTS: On all items, patients with PHL scored worse than did their controls. We found the largest differences in frequencies of symptoms of disequilibrium, difficulties with speech or swallowing, the Timed Walking Test, and the body care and movement subscale of the Sickness Impact Profile. Except for disequilibrium (p = 0.04), these differences did not reach statistical significance. Abnormal tandem-walking tests were more frequent in patients than they were in controls. Pyramidal signs were equally distributed. CONCLUSIONS: We propose PHL as a cause of symptoms of disequilibrium in patients with atherosclerosis. Symptoms are probably elicited by dysfunction of the corticopontine fibers, the pontocerebellar fibers, or the pontine nuclei.     

Clinical assessment of extrapyramidal signs in nursing home patients given antipsychotic medication

BACKGROUND: We sought to quantify the relationship between antipsychotic drug use and clinical evidence of extrapyramidal dysfunction in a large population of elderly nursing home patients. METHODS: Subjects were 251 residents (mean age, 84.1 years; range, 65 to 105 years) who were taking psychoactive drugs in 12 long-term care facilities. Patient characteristics and all medication use (both scheduled and as needed) were measured during a 1-month observation period. We then performed neuropsychological and functional testing on residents who received any psychoactive medications during the study month. The presence of rigidity, bradykinesia, or masklike facies was assessed in each patient by a research assistant who was unaware of diagnoses and medication use. RESULTS: The parkinsonian signs studied were found in 127 (50.6%) of these residents. Using logistic regression modeling to adjust for potential confounding, we found this outcome to be increased more than threefold in patients who took low-potency neuroleptics (odds ratio [OR], 3.49 for > or = 50 mg/d of chlorpromazine-type drugs; 95% confidence interval [CI], 1.28 to 9.57) and more than sixfold for use of 1 mg/d or more of haloperidol (OR, 6.42; 95% CI, 2.16 to 19.04). Age, gender, and use of nonneuroleptic psychoactive drugs were not associated with an increase in parkinsonian signs. CONCLUSIONS: Clinical evidence of extrapyramidal dysfunction is three to six times more common in institutionalized elderly patients given antipsychotic medication than in comparable patients not using such drugs. Its risk is substantially increased even in patients given low-potency chlorpromazine-type drugs, as well as those taking haloperidol. The effect is not explained by age or mental status and is not seen with other psychoactive medications. The expected frequency of parkinsonian symptoms can help to inform the balancing of risks vs therapeutic effect when the use of all drugs in this class is considered.     

Vulnerability to specific life events and prediction of course of disorder in unipolar depressed patients.

Tested a cognitive-life stress integrative model that predicted depressive symptoms following stressful life events when the negative events were personally meaningful to the individual, and likely to be interpreted as depletions or failure in the domain of central relevance to self-worth. 27 unipolar depressed outpatients completed a sociotropy-autonomy scale and were followed prospectively for periods of up to 2 yrs, with periodic assessments of life events and symptoms. As predicted, Ss' periods of worst symptoms followed a 3-mo period in which life event stress that matched their personally relevant domain significantly exceeded that of the nonrelevant domain. For Ss who experienced an onset following a symptom-free period, the severity of symptoms was significantly predicted by the interaction of their autonomy score and achievement events; however, the same pattern did not occur for sociotropy score and interpersonal events. (French abstract) (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Licking behavior in the rat: measurement and situational control of licking frequency

OBJECTIVE: In a preliminary report, the authors observed that clozapine was superior to haloperidol in the treatment of positive and negative symptoms in stable outpatients with schizophrenia. In this final report, they examine the effects of clozapine on positive and negative symptoms in patients with and without the deficit syndrome to determine which patients receive the positive symptom advantage of clozapine and the extent of clozapine's therapeutic effects on negative symptoms. In addition, they examine the long-term effects of clozapine on positive, negative, and affective symptoms, social and occupational functioning, and quality of life. METHOD: Seventy-five outpatients with schizophrenia, who met retrospective and prospective criteria for residual positive or negative symptoms, were entered into a 10-week double-blind, parallel-groups comparison of clozapine and haloperidol. Patients who completed the double-blind study were then entered into a 1-year open-label clozapine study. RESULTS: For patients who completed the 10-week double-blind study, clozapine was superior to haloperidol in treating positive symptoms. This effect was not observed in the intent-to-treat analyses. There was no evidence of any superior efficacy or long-term effect of clozapine on primary or secondary negative symptoms. Long-term clozapine treatment was associated with significant improvements in social and occupational functioning but not in overall quality of life. CONCLUSIONS: For schizophrenic patients who are able to tolerate clozapine therapy, clozapine has superior efficacy for positive symptoms but not negative symptoms and is associated with long-term improvements in social and occupational functioning for patients with and without the deficit syndrome.     

Body dysmorphic disorder in patients with acne

There is growing evidence that the prevalence of body dysmorphic disorder (BDD) is significantly higher in specially selected populations as compared to the general population. The goal of the current study was to evaluate prevalence of BDD in Turkish patients with mild acne presenting to a dermatologist for treatment. This study was the first empirical investigation of BDD in acne patients in Turkey. One hundred fifty-nine outpatients diagnosed with acne who consulted to the dermatology clinic were included in the study. The diagnosis of BDD was based on DSM-IV criteria and the Structured Clinical Interview for DSM-IV (SCID-I). A study-specific questionnaire was administered to document and investigate the demographic and clinical characteristics of the cases. Fourteen (8.8%) patients were diagnosed with BDD. Three (21.4%) patients with acne and BDD also had concomitant psychiatric diagnoses. All of the patients were psychiatric management-naive, never received any psychological or physical treatments. BDD was a common psychiatric condition in acne cases. We suggest that dermatologists should routinely explore symptoms and screen such patients for BDD.     

Urinary tract infection: bacterial adhesin and biofilm formation]

Localized botulinum toxin injection disrupts cholinergic transmission and has potential to cause focal dysautonomia. Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission. We questioned whether patients who receive Botox injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions. Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections. Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach. One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness. Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty. These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.     

Diagnostic accuracy would be improved by developing more categories of "non-disease"

Studies on the ways in which doctors think have shown the importance of intuitive processes in the formulation of a diagnosis. They have also suggested that intuitively generated diagnoses are used to aid the memory of relevant clinical facts during a clinical consultation. Only some symptoms and signs can be ordered into or subsumed under a diagnostic label. Others, which have not been thought of as constituting a disease, will tend to be lost from memory. If a diagnosis were to be thought of, not as the label of a disease but as a mental construct by means of which data are ordered and remembered, that is, as an invention whose utility is to be judged by the degree to which clinical thinking is facilitated, it would become reasonable to develop diagnoses to cover larger areas of clinical phenomenology. Some examples of the usefulness of such diagnoses of "non-disease" are given ant it is suggested that clinical thinking might be improved by the wider use of the concept.     

Early syphilis in an active duty military population and the surrounding civilian community, 1985-1993

The study of human aggression has been hindered by the lack of reliable and valid diagnostic categories that specifically identify individuals with clinically significant displays of impulsive aggressive behavior. DSM intermittent explosive disorder (IED) ostensibly identifies one such group of individuals. In its current form, IED suffers from significant theoretical and psychometric shortcomings that limit its use in clinical or research settings. This study was designed to develop a revised criteria set for IED and present initial evidence supporting its reliability and validity in a well characterized group of personality disordered subjects. Accordingly, research criteria for IED-Revised (IED-R) were developed. Clinical, phenomenologic, and diagnostic data from 188 personality disordered individuals were reviewed. IED-R diagnoses were assigned using a best-estimate process. The reliability and construct validity of IED-R were examined. IED-R diagnoses had high interrater reliability (kappa = .92). Subjects meeting IED-R criteria had higher scores on dimensional measures of aggression and impulsivity, and had lower global functioning scores than non-IED-R subjects, even when related variables were controlled. IED-R criteria were more sensitive than DSM-IV IED criteria in identifying subjects with significant impulsive-aggressive behavior by a factor of four. We conclude that in personality disordered subjects, IED-R criteria can be reliably applied and appear to have sufficient validity to warrant further evaluation in field trials and in phenomenologic, epidemiologic, biologic, and treatment-outcome research.