Adapting milieu approaches to acute inpatient care for schizophrenic patients

Classic therapeutic community or milieu therapy techniques are not applicable in many contemporary acute-treatment settings, which emphasize crisis intervention, short stays, psychotropic medication, and cost containment. However, milieu techniques can be integrated with an understanding of biological and psychosocial factors to provide a framework for the acute, short-term treatment of schizophrenic patients. After reviewing recent biological and psychosocial research, the authors outline three principles for incorporating such research with milieu techniques: creating a holding environment, developing a graduated therapeutic program, and focusing on common patient needs. Application of these principles in a short-stay setting will provide an intensely supportive treatment environment that allows the use of many different therapies and modulates stresses on staff.

Pancreatic pseudotumors associated with multifocal idiopathic fibrosclerosis

Two patients with multifocal idiopathic fibrosclerosis and sclerosing cholangitis developed biliary obstruction due to a fibrotic pancreatic pseudotumor. The masslike fibrosis mimicked pancreatic carcinoma on sonography and cholangio-pancreatography. In one patient sonography was successfully used to assess the response of the pseudotumor to corticosteroid therapy.

Localization and expression of mRNA for a macronuclear-specific histone H2A variant (hv1) during the cell cycle and conjugation of Tetrahymena thermophila

hv1 is a histone H2A variant found in the transcriptionally active Tetrahymena macronucleus but not in the transcriptionally inert micronucleus. This, along with a number of other lines of evidence, suggests that hv1 is associated with active genes. We have used a cDNA clone as a probe to study hv1 mRNA accumulation throughout the cell cycle and during conjugation. In situ hybridization to glutaraldehyde-fixed growing cells, whose position in the cell cycle was determined by size and morphology, showed that hv1 message is present throughout the cell cycle. The message was uniformly distributed in these vegetative cells. Compared with four other Tetrahymena histone genes studied to date (S. -M. Yu, S. Horowitz, and M. A. Gorovsky, Genes Dev., 1:683, 1987; M. Wu, C. D. Allis, and M. A. Gorovsky, Proc. Natl. Acad. Sci. USA 85:2205, 1988), hv1 mRNA is the only one that does not show a pattern of accumulation during the cell cycle that could explain the nuclear localization of its encoded protein. Thus, either hv1 or some molecule with which it associates contains a macronuclear-specific targeting sequence or there exists a cell cycle-regulated event that restricts its translation to the macronuclear S phase. In situ hybridization to conjugating cells revealed that hv1 message amounts increase just prior to macronuclear development and decline precipitously after the cells separate. The hv1 message showed no marked subcellular localization and is, therefore, unlikely to play a role in the cytoplasmic determination known to occur during macronuclear development.

Drosophila has a single copy of the gene encoding a highly conserved histone H2A variant of the H2A.F/Z type

The Tetrahymena histone H2A variant designated hv1 is localized exclusively in the transcriptionally active macronucleus and is absent from the quiescent micronucleus (1). A cDNA clone of the hv1 gene (2) was used to screen a Drosophila cDNA library. A cross-hybridizing clone was recovered and shown by sequence analysis to code for a protein homologous to hv1 as well as to the chicken H2A variant, H2A.F (3), the sea urchin H2A variant, H2A.F/Z (4) and the mammalian H2A variant H2A.Z (5). Southern analysis of Drosophila genomic DNA indicates that the H2AvD (H2A variant Drosophila) gene is present in one copy. In situ hybridization places the locus at 97CD on chromosome 3, while the S-phase regulated histone genes are on chromosome 2 (6). Thus the Drosophila H2A variant should be accessible to genetic analysis, which will enable its function to be determined.

Sequence and properties of the message encoding Tetrahymena hv1, a highly evolutionarily conserved histone H2A variant that is associated with active genes

hv1 is a histone H2A variant found in the transcriptionally active Tetrahymena macronucleus, but not in the transcriptionally inert micronucleus. hv1 also contains antigenic determinants conserved in the histone complements of representatives of all four eukaryotic kingdoms. A cDNA clone encoding hv1 has been isolated and sequenced. Comparison of the derived protein sequence of hv1 with that of the chicken variant H2A.F and the sea urchin variant H2A.F/Z reveals remarkable homology in all but the extreme amino- and carboxy-termini and a small region in the conserved core. Putative regions of conserved antigenicity are discussed. Evidence is presented that suggests that hv1 is a single-copy, intron-containing gene that encodes a polyadenylated message. Unusual features in the 3' flanking sequence and in codon usage are also described. Evidence is also presented showing that hv1 message amounts are ten-fold greater in growing cells than in starved cells.

Low-level echogenicity in intraventricular hemorrhage versus ventriculitis

Serial cranial sonograms of 55 neonates with large perinatal intraventricular/intraparenchymal hemorrhages and moderate-to-severe posthemorrhagic hydrocephalus were reviewed. In all 55 patients, the ventricles were initially enlarged and filled with anechoic cerebrospinal fluid, which contained discrete hyperechoic fragments of hematoma. Between 7 and 25 days after the initial hemorrhagic episode, however, diffuse, low-level echogenicity appeared in the ventricles of 34 patients. The low-level echogenicity was transient and persisted for 7-59 days (average, 18 days). In 32 patients, low-level echogenicity was a benign finding associated with prior intraventricular hemorrhage. In two patients, the low-level echogenicity was associated with ventriculitis. Low-level echogenicity appeared, increased, then cleared, but reappeared with the onset of ventriculitis in these two patients. Thickening of the ependyma and abnormal periventricular echogenicity, signs of inflammation, were also present. Although low-level echogenicity may commonly be a benign finding, the possibility of ventriculitis should not be ignored.

Cranial duplex sonography of the infant

Duplex sonography was used to evaluate the cranial contents of 75 infants. The first 35 were scanned to establish technique and evaluate basic flow patterns. All cranial vessels scanned in healthy term infants produced diphasic (low-resistance) waveforms, although certain cerebral vessels had characteristic Doppler signatures. The pericallosal, callosomarginal, anterior cerebral, basilar, middle cerebral, and internal carotid arteries and the vein of Galen were isolated and evaluated in almost every subject. In the second part of the study duplex characteristics of healthy term infants, healthy preterm infants, preterm infants with intracranial hemorrhages, and hydrocephalic infants were evaluated. Relative flow velocity at peak systole and end diastole and pulsatility index were investigated. The most significant variable was gestational age. Preterm infants frequently had no forward flow during diastole. Duplex sonography does not appear to add significant diagnostic information to routine real-time cranial studies. It does, however, permit more exact evaluation of cerebral blood flow than does non-pulse-gated, nondirected Doppler scanning.

Renal metastases: clinicopathologic and radiologic correlation

The clinical and radiologic features of 27 patients with renal metastases arising from eight different types of nonlymphomatous primary malignancies are presented. Renal metastases were generally detected late in the course of the malignancy. In 23 patients there were no symptoms referable to the kidney. Urinalysis was normal in nine patients and showed microscopic hematuria in nine, gross hematuria in four, and proteinuria in four. Radiologically, metastases were usually multifocal; however, metastases arising from colon, lung, and breast carcinoma were sometimes large, solitary, and otherwise indistinguishable from primary renal cell carcinoma. Three of four melanoma metastases and three of seven lung metastases infiltrated the perinephric space. Computed tomography was the most sensitive modality, depicting renal metastases in all 24 cases in which it was employed, followed by ultrasound and intravenous urography. In patients with a history of malignancy, renal metastases outnumbered renal cell carcinomas by approximately 4:1. This study indicates that a new renal lesion in a patient with advanced, noncurable cancer is more likely metastatic than primary and that biopsy in this setting is unlikely to be of aid.

Focal periportal sparing in hepatic fatty infiltration: a cause of hepatic pseudomass on US

An unusual pattern of hepatic fatty infiltration was detected sonographically in 31 patients over a 1.5-year period. At appropriate gain settings and time gain compensation, the liver parenchyma demonstrated diffuse increased echogenicity except for a solitary hypoechoic area with relatively distinct margins, usually located in the medial segment of the left hepatic lobe. This hypoechoic periportal focus varied in size between 1.5 and 5 cm and was typically ovoid, but was occasionally spherical or irregular in shape. Eight patients with such foci underwent percutaneous needle biopsy because of concern that there was a space-occupying mass. Microscopic examination of specimens from the hypoechoic periportal region revealed normal hepatic parenchymal cells, while tissue samples from the surrounding liver had high fat levels. In the remaining 23 patients, correlative radiologic studies supported the diagnosis of fatty liver and excluded a central-mass lesion. A localized area of normal hepatic tissue should be considered among the possible diagnoses when a circumscribed hypoechoic periportal area is demonstrated within a fatty liver.

Enzyme activity dot blots: a rapid and convenient assay for acetyltransferase or protein kinase activity immobilized on nitrocellulose

Methods are described for assaying (Tetrahymena) histone acetyltransferase activity and (Drosophila) casein kinase II activity by spotting extracts on nitrocellulose filters. The methods are quantitative over a wide range of enzyme concentrations and are almost as sensitive as liquid assays. Examples are presented for illustrating the use of these methods for enzyme purification, concentration, and desalting, as well as for electrophoretic blotting from agarose gels. A simple method for autoradiographic enhancement of nitrocellulose filters is also described.

Intravascular signal in MR imaging: use of phase display for differentiation of blood-flow signal from intraluminal disease

Intravascular signal from flowing blood is frequently observed on magnetic resonance (MR) images and may be indistinguishable from partial or complete vascular occlusion caused by thrombus or tumor. With a phase-display reconstruction method, qualitative assessment of large-vessel patency within the abdomen was undertaken in 15 healthy subjects and 12 patients with angiographically or surgically documented intravascular thrombus or tumor. Computed tomographic (CT) scans were available in all patients for correlation. MR studies were performed with a multisection spin-echo pulse sequence and two-dimensional Fourier transform spatial encoding. Data acquired from a single sequence was reconstituted in two ways to provide both routine anatomic images and a pictorial representation of large-vessel flow on a phase-sensitive image. With this method, reliable and easy differentiation of intraluminal thrombus and tumor from blood flow signal within large vessels was achieved. Information from these phase-display images compared favorably with findings from angiography and contrast-enhanced CT in the determination of luminal patency and obstruction.

Pediatric neurosonography

Neurosonography is an excellent modality for imaging a wide array of intracranial pathology in the infant and newborn. Neurosonography is also finding increasing use in other accessible regions of the central nervous system, including the adult brain during craniotomy and the spine during laminectomy. Sonography represents the primary modality for the evaluation of the preterm brain. Because of the high incidence of pathology in gestationally immature neonates, screening sonography is required in every infant. The sonographic features of intracranial hemorrhage include areas of increased echogenicity in the region of the germinal matrix, within the ventricles, or in the surrounding cerebral parenchyma. Careful follow-up of these children for sometimes severe posthemorrhagic hydrocephalus is essential. Premature neonates are also at risk for ischemic disease, particularly periventricular leukomalacia, which is accurately diagnosed sonographically and implies a poor prognosis in almost every infant so affected. Cranial sonography is also an excellent method to evaluate abnormalities that are not associated with gestational immaturity. Cranial sonography offers excellent anatomic imaging of the brain when evaluating for congenital anomalies; because sections may be obtained in a multitude of orientations, sonography is actually more versatile than computed tomographic (CT) scans. Cranial sonography is also of use when evaluating children with inflammatory processes such as ventriculitis; sonography is superior to CT scans in identifying intraventricular septae typical of the process. Intrauterine inflammatory processes, however, are frequently associated with intracranial calcifications, CT scans may be more accurate in these cases. CT scans may also be more efficacious in the diagnosis of subdural, epidural, and subarachnoid hemorrhage. Intracranial neoplasms are rare in the younger population and although they are visible with ultrasound, CT scans with contrast are essential in an effort to obtain added information and because of a greater experience using CT scans. Sonography represents an excellent modality with which to evaluate the infant and neonatal brain. In a number of diseases it may be diagnostic alone. The informed clinician, however, should keep in mind those instances where a complimentary modality such as CT scanning can add additional or even essential information.

Pancreatic necrosis: CT manifestations

Pancreatic necrosis is a potential sequela of acute pancreatitis, which pathologically represents a collection of devitalized tissue. Appropriate therapeutic planning requires definition of this irreversibly damaged gland, the presence of which is not consistently diagnosed on the basis of clinical and laboratory data. Over an 18-month period, 22 patients with pancreatic necrosis were studied by one or more computed tomographic (CT) examinations. Retrospective analysis showed the findings to vary with the developmental stage of the necrotizing process. During the acute phase, there was considerable morphologic overlap of necrosis and pancreatic phlegmon. Typical findings were seen in the subacute and chronic stages and included diffuse enlargement of the gland with largely decreased central density. A thick, smooth surrounding rim produced a characteristic saclike configuration. CT-guided aspiration for culture material was performed in four patients with suspected superinfection. Negative gram stain and culture results in two patients allowed surgery to be performed on a more elective basis.

Drainage of pelvic abscesses through the greater sciatic foramen

A computed tomographic (CT) guided transgluteal approach through the greater sciatic foramen was used to drain pelvic abscesses and fluid collections in 21 patients. Ideal catheter placement should traverse the lower portion of the greater sciatic foramen at the level of the sacrospinous ligament. This avoids the vascular and neural elements that are located slightly cephalad at the level of the piriformis muscle. Percutaneous drainage through this approach was successful in avoiding surgery in 17 patients (81%). Pain was the most common complication and was generally associated with a more cephalad approach, transgressing the piriformis and the sacral plexus. CT-guided percutaneous drainage of pelvic abscesses through the greater sciatic foramen should be used when the more standard transperitoneal approach is not possible.

Corn mitochondrial protein synthesis in response to heat shock

Corn (Zea mays L., W23(N), OH43(N), and reciprocal single cross hybrid) seedling mitochondria respond to a 10 degrees C temperature shift (27-37 degrees C) by incorporating a greater amount of [(35)S]methionine into acid-insoluble material than mitochondria incubated at the original growing temperature (27 degrees C). This increase is in part manifested in the enhanced synthesis of a 52 kilodaltons protein. At both temperatures mitochondria of two inbreds and their reciprocal hybrids synthesize normal (N) cytoplasm proteins sensitive to chloramphenicol and insensitive to cyclohexamide treatment. The 52 kilodaltons protein is found in the supernatants of pelleted (15,000g, 5 min) mitochondria after heat shock. The role of this protein in the heat shock response is discussed in light of the implication of mitochondria as the primary cellular target to temperature stress.

Surface coil MR imaging of abdominal viscera. Part III. The pancreas

Eight healthy volunteers and 11 patients with pancreatic abnormalities were studied using a conventional body coil and a prototype magnetic resonance (MR) surface coil. Final pathologic diagnoses included carcinoma of the head (six), body (one), and tail of the pancreas (two) and chronic pancreatitis (two). In surface coil images of the volunteers, the body and tail of the pancreas was visualized in all cases but one, and the pancreatic duct was seen in five of eight cases. In-plane spatial resolution of 0.9 X 0.9 mm and 5-mm section thickness was obtained. At the same time, pancreatic surface coil images had a twofold improvement in the signal-to-noise ratio (SNR) compared with body coil images. T1-weighted spin-echo images gave greater SNR, reduced motion artifacts, provided superior anatomic detail, and offered more diagnostic information than comparable T2-weighted images. Significant abnormalities detected only by surface coil imaging included a small tumor surrounded by reactive edema and periglandular tumor invasion. This study demonstrates that surface coil imaging of the pancreas not only is feasible but provides an improved method for examining the pancreas by MR.

Surface coil MR imaging of abdominal viscera. Part I. Theory, technique, and initial results

Prototype surface coil magnetic resonance (MR) images were obtained from phantoms and 42 subjects at 0.6 T to assess the feasibility of imaging relatively deep abdominal structures. Surface coil images demonstrated a two- to fourfold improvement in signal-to-noise ratio (SNR) when compared with whole-body coil images with the same resolution elements. This improvement in SNR allowed us to obtain images with thinner sections, higher in-plane resolution, or, alternatively, a decrease in image time. Compared with body images, surface coil images demonstrated greater anatomic detail and reduction in motion artifacts. Despite the limited field of view in very large patients, the use of surface coils improves the diagnostic capability of MR imaging of the abdomen.

Surface coil MR imaging of abdominal viscera. Part II. The adrenal glands

Magnetic resonance (MR) imaging of the adrenal glands with a prototype surface coil was compared with conventional body coil images in five healthy volunteers and 15 patients with adrenal disease. The spectrum of abnormalities included five nonfunctioning cortical adenomas, of which two were in hyperplastic glands, four adrenal metastases, three pheochromocytomas, a functioning adenoma, a myelolipoma, and a partially calcified, cystic adrenal mass. In both body and surface coil images, anatomic detail was superior on T1-weighted images compared with T2-weighted images obtained with identical imaging time because of decreased motion artifact and superior contrast. In the T1-weighted studies, high-resolution surface coil images showed a threefold improvement in signal-to-noise ratio (SNR) over body coil images, which was manifest by better intrinsic resolution of small adrenal lesions and clearer definition of the extrinsic relationships of large masses to nearby organs. In addition, inferior vena caval invasion by two right adrenal metastases was better demonstrated using the surface coil than body coil MR or computed tomography (CT). Limitations of surface coil imaging include restriction in the field of view to a single gland and additional time required for patient positioning. Since the sensitivity of surface coils diminishes with depth, gains in SNR were limited in large patients with deeper adrenal glands. Despite these limitations, dramatic improvements in SNR and anatomic resolution indicate that surface coil MR imaging will be competitive with CT for examining the adrenal glands.

Reversal of lower esophageal sphincter hypotension and esophageal aperistalsis after treatment for hypothyroidism

A 65-year-old woman suffered from both chronic gastroesophageal reflux, which was complicated by columnar metaplasia (Barrett's epithelium), and profound hypothyroidism. An esophageal motility tracing showed absence of peristalsis in the lower esophagus and the lower esophageal sphincter (LES) could not be identified. Thyroid replacement therapy, in conjunction with antacid and cimetidine treatment, was associated not only with improvement in the gastroesophageal reflux symptoms, but also with a return of esophageal peristalsis and LES pressure to normal. To support our clinical observations, we rendered four cats hypothyroid with 131I and documented a fall in LES pressure. We propose that abnormal smooth-muscle function of the esophagus may be another manifestation of the gastrointestinal motility disturbances which are associated with hypothyroidism.