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.     

Biosynthesis of the ansamycin antibiotic rifamycin: deductions from the molecular analysis of the rif biosynthetic gene cluster of Amycolatopsis mediterranei S699

Depression is a common disorder which causes intense personal suffering and socio-occupational dysfunction. It also imposes a heavy economic burden on society. It has been shown that between 29% and 46% of depressed patients fail to respond adequately to antidepressant medication. Treatment-resistant depression may contribute to the morbidity and mortality associated with affective illness. When treatment resistance is suspected, the patient's history should be reevaluated particularly regarding diagnostic subtypes and comorbidity. An assessment of treatment adequacy in terms of dose, duration and compliance should also be made. Treatment strategies for treatment-resistant depression should be systematic and empirically grounded because of the risk of increased resistance and loss of time in case of a random trial-and-error approach, and the inherent risks in certain novel strategies. A stepped care approach to treatment-resistant depression involves optimization of the current drug under trial, augmentation with drugs such as lithium and triiodothyronine, and switching to other somatic therapies such as electroconvulsive therapy and monoamine inhibitors. Only if these strategies fail, should novel treatments such as the use of venlafaxine, antidepressant combinations and augmentation with sleep deprivation be considered. Experimental strategies such as the use of antiglucocorticoids and sex hormones, which carry considerable risk, should be restricted to research settings. Somatotherapy should be combined in all cases with depression-specific psychotherapy. Psychosurgery should be considered only in truly intractable cases. Rational and energetic treatment can adequately help a large majority of patients with treatment-resistant depression.     

Transient kinetics and thermodynamics of anthroylouabain binding to Na/K-ATPase

In this study the antiarrhythmic and the proarrhythmic activities of almokalant, a selective class III antiarrhythmic agent, were compared. The antiarrhythmic effect of the drug was tested in pentobarbital-anaesthetised rabbits. Arrhythmia was evoked by occluding and releasing the left circumflex coronary artery. Almokalant in a dose of 250 nmol/kg i.v., significantly decreased the incidence of reperfusion induced ventricular fibrillation (21% vs. 75% in the control group) and increased the proportion of surviving animals during reperfusion (86% vs. 42%). The proarrhythmic effect of almokalant was examined during alpha1-adrenoceptor stimulation in chloralose-anaesthetised rabbits. Almokalant (75 nmol/kg per min) triggered torsade de pointes arrhythmias in 8 animals out of 11. The dose of almokalant (mean+/-S.E.M.) required to produce this effect was 1181+/-519 nmol/kg. It is concluded that, although almokalant is an effective antiarrhythmic agent against ischaemia-reperfusion induced arrhythmias, it has marked proarrhythmic activity during alpha1-adrenoceptor stimulation.     

The dystonias

Acute anterior uveitis (AAU) is characterized by sudden-onset, mostly unilateral exacerbations of an inflammation of the iris and ciliary body. The duration of illness is short if the patient is treated with corticosteroids. Half of all patients with any type of anterior uveitis are HLA-B27-positive, and more than half of the B27-positive patients have spondyloarthropathy. Ophthalmologists should therefore refer all patients with AAU who are HLA-B27-positive to a rheumatologist. Because attacks of AAU are extremely painful and frightening, most spondyloarthropathy patients with AAU will seek out an ophthalmologist on their own. The anterior chamber of the eye and the joints are mesenchymal cavities that are cleaned by macrophages. Anterior chamber-associated immune deviation is the mechanism by which specific regulatory T cells normally produce sufficient transforming growth factor-beta to impair inflammatory reactions that might hamper vision. Another mechanism of immune privilege is Fas-ligand induced apoptosis. Because the cells of the anterior eye express Fas-ligand, infiltrating cells are apoptotically killed. Comparable mechanisms may occur at a lower level in joints. The cause of AAU and spondyloarthropathy is unknown. B27 is probably only responsible for one quarter of the pathogenesis, other non-B27 genetic factors for another quarter, and unknown exogenous factors for the remaining half. It is possible that Gram-negative bacteria such as Klebsiella or Yersinia are involved in the pathogenesis in a yet unknown way.     

Medical illness burden, trait neuroticism, and depression in older primary care patients

OBJECTIVE: The authors tested the hypotheses that medical illness burden is independently associated with depression and that this association is moderated by neuroticism. METHOD: Multiple regression techniques were used to determine the independent associations of medical burden and neuroticism with depression in a group of 196 subjects, 60 years of age and older, recruited from primary care settings. RESULTS: Medical burden and neuroticism were independently associated with major depression, depressive symptoms, and psychiatric dysfunction. CONCLUSIONS: These findings support models in which medical disorders may contribute directly to depression. At the same time, the role of neuroticism in later-life depression warrants further study.     

A method for open reduction and internal fixation of the unstable posterior sternoclavicular joint dislocation

Posterior sternoclavicular joint (SCJ) dislocations are most often stable after reduction but may be associated with significant complications related to the location of the medial head of the clavicle within the mediastinum. In rare instances, a posterior SCJ dislocation is irreducible or redislocates after a closed reduction. Because of the potential hazards related to compression of vital structures within the superior mediastinum, open reduction and internal fixation is usually required. Although open reduction is widely accepted as the method of choice, the best method for achieving stable fixation remains unanswered. We present the case of an unstable SCJ stabilized, in anatomic position, with two large-bore cannulated screws in conjunction with open reduction. We believe that the risk of hardware migration reported with the use of pins and wires and its catastrophic complications are greatly minimized using our technique.     

Clinical features and outcome in disseminated mycobacterial diseases in AIDS patients in Taiwan

OBJECTIVE: To describe and compare the clinical features and outcome of disseminated tuberculosis (TB) and Mycobacterium avium complex (MAC) disease in AIDS patients. DESIGN: Prospective cohort study. SETTING: A 1800-bed university teaching hospital, the largest centre for HIV/AIDS patients in Taiwan. METHODS: From July 1994 through June 1997, a standardized protocol was used to record the demographic and clinical features in all hospitalized HIV-infected patients, and to perform routine studies and invasive procedures for diagnosis of disseminated mycobacterial diseases. To compare the survival, control patients were selected from the HIV-infected patients hospitalized in the same hospital during the same study period, and had similar age, sex, CD4+ cell counts and antiretroviral therapy regimens. RESULTS: A total of 22 cases of disseminated TB and 15 cases of disseminated MAC were identified. Disseminated TB and MAC occurred in patients with similarly low CD4+ cell counts (median, 23 versus 5 x 10(6)/l; P = 0.08). The clinical features favouring disseminated TB included night sweats, peripheral lymphadenopathy, acid-fast bacilli in sputum smears, chest radiographic findings of hilar enlargement, and lack of prior AIDS-defining illnesses. Hepatosplenomegaly, elevated serum alkaline phosphatase (more than twice the upper limit of normal), elevated serum gamma-glutamyl transpeptidase (more than three times the upper limit of normal), and leukopenia favoured disseminated MAC. The patients with disseminated TB survived much longer than patients with disseminated MAC (mean survival, 96 versus 22 weeks, P = 0.008) but had a similar outcome to control patients (P = 0.60). CONCLUSION: Disseminated TB and MAC are distinguishable by clinical features in AIDS patients with similar immunocompromised states. Those features may facilitate diagnosis and selection of specific therapeutic regimens. Disseminated TB was not associated with a shortened survival period in AIDS patients when they completed anti-TB treatment. In contrast, disseminated DMAC was associated with shortened survival despite treatment with potent regimens. These results may emphasize the importance of prophylaxis for MAC in this population.