Geriatric psychiatry training in Canada: current teaching facilities and resources

A survey of Canadian psychiatry residency programs requested information on training activities in geriatric psychiatry. Fourteen out of sixteen programs responded. On average ten hours of didactic instruction were provided per year over the four years of the residency program. Only one program had no facility that provided a rotation in geriatric psychiatry. The majority of programs have policies that encourage exposure of trainees to the care of the elderly. There is a concentration of teachers of this sub-specialty in a minority of centres. These findings are discussed in the light of current and future needs in the care of the elderly. Recommendations for meeting these are proposed.

Functional hyposplenia in a child with the AIDS-related complex

Functional hyposplenia can be defined as decreased splenic phagocytosis. A case of functional hyposplenia is reported in a child with AIDS-related complex.

Impaired immune function in obstructive jaundice

Sepsis is a common and occasionally lethal complication of obstructive jaundice. The reasons for this increased susceptibility to infection are unknown. This study examines lymphocyte and reticuloendothelial (RES) function in animals with obstructive jaundice. Twelve New Zealand white rabbits (3-4 kg) were studied. Lymphocyte function was evaluated in six rabbits by phytohemagglutinin (PHA), concanavalin A (Con A), and pokeweed mitogen (PWM) stimulation. In six animals, hepatic RES function was assessed by calculating the phagocytic index (PI) using the disappearance of 99Tc sulfacolloid (5 mg/kg) iv. After baseline studies, the common bile duct was divided and ligated. The above studies and serum bilirubin were repeated at 3 weeks. Obstruction was then relieved by cholecystojejunostomy (CJ) and RES studies repeated monthly x 6. Preobstructive lymphocyte function showed a stimulation index ratio (log) of 0.85 +/- 0.25 for PHA, 0.75 +/- 0.3 for Con A, and 0.71 +/- 0.25 for PWM. With biliary obstruction, the values fell to -0.23 +/- 15 (P less than 0.006), -0.31 +/- 0.12 (P less than 0.006), and -0.29 (P less than 0.006), demonstrating impaired lymphocyte function. When tested lymphocytes were mixed with control pooled rabbit serum, however, no lymphocyte impairment was noted. Baseline hepatic PI was 6.02 +/- 0.18 and fell to 3.79 +/- 0.33 with obstruction (P less than .01) and remained low at (3.20 +/- 0.14) 1 month (P less than 0.01) and (3.33 +/- 0.23) at 3 months (P less than .01), after CJ but returned to normal (8.04 +/- 0.97) at 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

HIPDM-SPECT in patients with medically intractable complex partial seizures. Ictal study

Both interictal and ictal N,N,N'-trimethyl-N'-(2-hydroxy-3-methyl-5-iodobenzyl)-1,3,propanediamine -single photon emission computed tomography (HIPDM-SPECT) were performed in 16 patients with medically intractable complex partial seizures. Ictal HIPDM-SPECT localized epileptic foci in 13 of 14 patients with unilateral temporal focus and provided confirmative evidence of epileptic focus in 11 patients by demonstrating maximally increased regional cerebral perfusion (rCP) in epileptic foci that had shown decreased rCP in a previous interictal study. Ictal HIPDM-SPECT in two patients with bitemporal foci showed more complicated patterns consisting of slightly increased rCP in bilateral multifocal regions. Ictal HIPDM-SPECT was particularly useful for investigating epileptic foci, and correlation with simultaneously recorded ictal electroencephalograms provided further insight for localizing epileptic foci.

HIPDM single photon emission computed tomography brain imaging in partial onset secondarily generalized tonic-clonic seizures

HIPDM-Single photon emission computed tomography brain imaging was performed during interictal and ictal stages in three patients with complex partial seizures and secondarily generalized tonic-clonic seizures. In all three patients, interictal studies demonstrated decreased regional cerebral perfusion (rCP) and ictal studies showed increased rCP in the epileptogenic region. The demonstration of focal hyperperfusion by SPECT performed during secondarily generalized tonic-clonic seizures suggests that rCP in the epileptic focus remains higher than in other cerebral regions during immediate postictal stages, even in secondarily generalized seizures.

Efficacy of thyroid scintigraphy in the diagnosis of intrathoracic goiter

For evaluation of the usefulness of thyroid scintigraphy in the diagnosis of intrathoracic goiter, we analyzed the results of radionuclide thyroid scintigraphy in 54 consecutive cases with suspected upper mediastinal masses. Intrathoracic goiters were found in 42. The sensitivity, specificity, and accuracy of the scintigraphy for intrathoracic goiter were 93% (39/42), 100% (12/12), and 94% (51/54), respectively. Scintigraphic morphology, scanning technique, and pitfalls are discussed. The results show that most intrathoracic goiters do have thyroid function and that radioiodine scintigraphy is a definitive and cost-effective diagnostic procedure for this disease.

DSM-III: problems in diagnosis of paranoia and obsessive-compulsive disorder

The diagnoses of paranoia and obsessive-compulsive disorder are not adequately dealt with either conceptually or phenomenologically in DSM-III. A case of monosymptomatic hypochondriacal psychosis illustrating this point is presented. The question of whether this disorder should be diagnosed as paranoia, obsessive-compulsive disorder or an atypical affective disorder is discussed.

Uptake of technetium 99m MDP by hepatoblastoma

Focal uptake of 99mTc-MDP was seen in a case of hepatoblastoma. The focal uptake corresponded to an area of calcification on CT, which was shown histologically to consist of osteoid with mineralization. The mechanism of uptake by the tumor in this case is likely to be the same as for skeletal uptake.

Detection of acute gastrointestinal bleeding by intra-arterial Tc-99m sulfur colloid scintigraphy in a canine model. Preliminary study

The diagnostic sensitivities of arteriography, intravenous (IV) Tc-99m sulfur colloid scintigraphy, and intra-arterial (IA) Tc-99m sulfur colloid scintigraphy were evaluated in a canine model of gastrointestinal bleeding. Fifteen dogs were studied at bleeding rates ranging from .4 to 1.0 ml/minute. All three studies were obtained in six of the 15 dogs. Intravenous scintigraphy was superior to angiography in two cases, inferior in three, and equal in one. No significant difference could be shown between these two tests at these bleeding rates. Intra-arterial scintigraphy was superior to angiography in four cases and equal in two (P = .06). It was superior to IV scintigraphy in five cases and inferior in one (P = .10). In this small preliminary study, IA scintigraphy appears to be superior to the other two modalities and may prove useful in the detection of acute bleeding at the time of negative arteriography, and in serial studies in patients receiving Pitressin.

Psychiatric residents' experience and career interest in geriatric psychiatry: implications for training programs

A survey of residents' experience and career interest in geriatric psychiatry was carried out in Canadian training centres. Residents' exposure to specific training experiences in geriatric psychiatry has been steadily increasing, although a large proportion of residents continue to report insufficient amount of experience and supervision in this area. Residents viewed geriatric psychiatry as involving special skills and knowledge and half were in favour of a compulsory rotation in this area. Geriatric psychiatry was an infrequent career choice along with other areas of psychiatry that have had difficulty in recruiting. Alternative approaches to service provision and recommendations for meeting the manpower needs are discussed.

Single photon emission computed tomography (SPECT) brain imaging using N,N,N'-trimethyl-N'-(2 hydroxy-3-methyl-5-123I-iodobenzyl)-1,3-propanediamine 2 HCl (HIPDM): intractable complex partial seizures

HIPDM-SPECT brain imaging was performed in four patients with intractable complex partial seizures (CPS). Three patients had an epileptogenic focus in one temporal lobe and underwent anterior temporal lobectomy. Interictal HIPDM-SPECT demonstrated decreased regional cerebral perfusion (rCP) in the epileptogenic area in only one patient, but ictal studies showed increased rCP in the epileptic foci of all three patients. In the fourth patient, interictal HIPDM-SPECT showed increased rCP in the area of epileptogenic focus; when antiepileptic medication was taken, rCP decreased. HIPDM-SPECT brain imaging is useful for localizing epileptogenic foci in CPS.

Different patterns for bile leakage following cholecystectomy demonstrated by hepatobiliary imaging

Tc-99m labeled iminodiacetic acid (Tc-99m IDA) studies were performed in three patients with bile leaks. The radiotracer distribution was different in all three. A diffuse peritoneal pattern was seen in one patient. Localized radioactivity was seen in two; in one in the gallbladder bed and in the other in the perihepatic region.

Localization of technetium-99m pertechnetate in peripheral nerve tumors

Technetium-99m pertechnetate scintigraphy in three patients with pathologically proven peripheral nerve tumors (six in total) demonstrated its ability to assess accurately the size, location, and the extent of all lesions. Pertechnetate localized only in areas of abnormal nerve involvement and all lesions were better seen in delayed images than the earlier ones. Pertechnetate imaging appears to be a promising method of noninvasive evaluation of clinically evident and occult tumors of peripheral nerve origin.

Indeterminate lung imaging. Can the number be reduced?

During a 2 1/2-year period, 1131 patients with suspected pulmonary embolism had ventilation-perfusion lung scans; 150 of these patients also underwent pulmonary angiography. In a retrospective study, these 150 patients were re-evaluated using the reference criteria of Biello and Alderson, with 62% read as indeterminate. Twenty patients who had chronic obstructive pulmonary disease with retention of Xe-133 in greater than 50% of the lung fields without corresponding radiographic abnormality were included. Ventilation/perfusion matches and mismatches could be correctly determined in 15 of these patients. These 15 of 20 studies could be correctly reclassified as low-probability, while the other five remained indeterminate. With increasing intervals between ventilation/perfusion lung imaging and the onset of symptoms, the percentage of patients with proven pulmonary emboli correctly diagnosed as high probability continuously decreased, and the percentage of studies read as indeterminate constantly increased. Serial chest radiographs suggested that the development of infiltrates in the region of the embolus convert high-probability ventilation/perfusion scans to indeterminate.

Acute paranoid disorder and Klinefelter's syndrome

A twenty-five-year old man presented with an acute paranoid disorder, and was subsequently diagnosed as having Klinefelter's Syndrome. Our review of previous reports suggests that the literature pointing out a particular association between Klinefelter's and schizophrenia may be misleading. In fact, Klinefelter's patients are liable to suffer from schizophrenia, paranoid disorders, or possibly other disorders.

The role of bone scintigraphy in osteogenic sarcoma

Hospital records of 27 children with osteogenic sarcoma were reviewed in an effort to define the usefulness of skeletal scintigraphy in the initial evaluation and follow-up of their disease. Serial bone scans as well as plain radiographs, linear tomograms, and computed tomograms were evaluated for evidence of bone or lung metastases. Eighteen patients developed lung metastases and three developed bone metastases. Seven patients demonstrated uptake of tracer in lung metastases, however, the lesions were all easily identifiable by radiographic means. All bone metastases were detected by scintigraphy, in one instance prior to radiographic abnormality. In no cases were bone metastases known to occur in the absence of lung metastases. None of the bone scans performed for routine follow-up purposes resulted in altered therapy for the patient. We propose that skeletal scintigraphy is useful in the initial metastatic work up of osteogenic sarcoma, and may be helpful in some patients with specific indications during their follow-up, but is less valuable when there is no clinical suspicion for bone metastases.

Thyroid abnormality secondary to tortuous carotid artery

A 59-year-old man was referred to the nuclear medicine service for a thyroid scan, as his neck was thick and the thyroid was not palpable. In the past the patient had undergone head and neck irradiation for acne. A 123I-thyroid scan was interpreted as a "cold" nodule in the lower pole of the right lobe, but thyroid ultrasound showed no thyroid abnormality. Repeat ultrasound examination eventually showed a tortuous carotid artery behind the lower pole of the right lobe of the thyroid that corresponded to the "cold" defect.