Diagnostic stability in subjects with multiple admissions for psychotic illness

BACKGROUND

Although studies investigating changes in diagnosis between psychotic episodes have differed in design, some consistent findings have emerged. This study seeks to clarify and extend these findings by describing and comparing clinical and operationally defined diagnostic stability in a group of subjects with multiple episodes of functional psychotic illness.

METHODS

The OPCRIT programme was applied to case notes of 204 subjects with multiple admissions for psychotic illness. Clinical and operationally defined diagnoses were compared and the spread and stability of diagnoses determined.

RESULTS

An increase in the frequency of diagnosis of schizophrenia from initial to subsequent episodes was demonstrated. High levels of stability were found for schizophrenia (58 to 98%), moderate levels for affective disorders (24 to 83%), low levels for other non-organic psychotic conditions (27 to 54%) and atypical psychosis (27 to 53%), and very low levels for schizoaffective disorder (5 to 39%) and other conditions (0 to 4%).

CONCLUSIONS

The stability levels for schizophrenia and affective disorders are adequate, but the low levels for a range of other psychotic conditions raise questions regarding their predictive validity.

A factor model of the functional psychoses and the relationship of factors to clinical variables and brain morphology

BACKGROUND

Despite more than 100 years of study, there remains no definitive diagnostic validation of the functional psychoses. Factor analysis suggests the presence of three or more psychopathological syndromes in functional psychoses as a whole. The relationship between these factors and cerebral anatomy has been investigated in schizophrenia only. This study aimed to address the relationship of symptom factors to clinically important variables and cerebral anatomy in a sample of psychotic patients with a spread of diagnoses.

METHODS

In a sample of patients with functional psychoses, symptom data was obtained on four consecutive admissions using the OPCRIT symptom checklist. OPCRIT data was used to generate operational diagnoses in accordance with pre-set criteria and a principle components analysis was performed on symptom data. Factor loadings were compared between each admission to examine factor stability over time. Factor scores at first admission were also correlated with clinical variables obtained from patients' case notes. From the sample of 204 patients, 64 subjects were recruited and underwent an MRI scan of the brain. Regional anatomical volumes were compared with diagnosis and factor loadings at first admission.

RESULTS

A principal components analysis gave a four-factor solution of 'manic', 'depressive', 'disorganization' and 'reality distortion' factors at each admission. Factors showed a high degree of stability over the four admissions studied. The factors were significantly associated with several clinical variables. Three of the four factors were associated with a specific pattern of cerebral anatomy.

CONCLUSIONS

This study suggests that factors may correspond to relatively specific disease processes underlying functional psychotic illness. We propose that the use of symptom factors may facilitate the investigation of the underlying mechanisms of psychotic illness.

Advantages of heterogeneous therapy groups in the psychotherapy of the traumatically abused: treating the problem as well as the person

The authors combine a social-constructionist perspective with a psychodynamic one in discussing the problem of trauma and its treatment. They argue that effective treatment of traumatic physical, sexual, and psychological abuse must do more than alleviate the pain of the sufferer. Factors that cause and perpetuate abuse must be addressed by the abused person in conjunction with other nontraumatized persons who may have been abusive or passive in the face of abuse. An argument is made for heterogeneous therapy groups as a context for this to occur.

Extra-anatomic urinary diversion

In five patients with chronic intractable ureteral obstruction, a fine-bore nephrostomy tube was placed in a subcutaneous tunnel to drain the kidney without an external appliance. Good quality of life was achieved for 6 months to 2 years. When conventional intraluminal stents cannot be used, consideration should be given to subcutaneous diversion rather than long-term nephrostomy tubes.

Subcutaneous urinary diversion: an alternative to percutaneous nephrostomy

Nephrostomy has been the standard method of urinary diversion when placement of ureteral stents has failed in cancer patients. We describe our early experience with an alternative method of urinary diversion, the subcutaneous urinary diversion. This extra-anatomical urinary diversion was done in 5 patients during a 15-month interval. The diversion is created using a specially designed 7F double pigtail stent. The proximal end of the stent is inserted into the renal pelvis via a percutaneous nephrostomy puncture. A subcutaneous tunnel is created from the flank to the bladder down which the distal end of the stent is passed and via a suprapubic bladder puncture the stent is passed into the bladder. The stent is changed at 4-month intervals over a guide wire. Our early experience with this extra-anatomical method of urinary diversion suggests it to be a safe, effective and acceptable alternative to nephrostomy that improves quality of life.

Combined nuclear and digital subtraction contrast arthrography in painful knee prosthesis

The evaluation of a painful knee prosthesis remains a difficult problem for both orthopaedic surgeons and radiologists. We have compared digital subtraction arthrography with nuclear arthrography in 7 patients with a painful knee prosthesis. Three patients showed a loose tibial component, demonstrated by both digital subtraction and nuclear arthrography. All 3 underwent revision of their prosthesis. One patient had an equivocal digital subtraction arthrogram and negative nuclear arthrogram, while both studies were negative in the 3 remaining patients. Nuclear arthrography is a simple procedure and can provide useful additional information when combined with digital subtraction arthrography.

Construction and properties of a mutant of herpes simplex virus type 1 with glycoprotein H coding sequences deleted

A mutant of herpes simplex virus type 1 (HSV-1) in which glycoprotein H (gH) coding sequences were deleted and replaced by the Escherichia coli lacZ gene under the control of the human cytomegalovirus IE-1 gene promoter was constructed. The mutant was propagated in Vero cells which contained multiple copies of the HSV-1 gH gene under the control of the HSV-1 gD promoter and which therefore provide gH in trans following HSV-1 infection. Phenotypically gH-negative virions were obtained by a single growth cycle in Vero cells. These virions were noninfectious, as judged by plaque assay and by expression of beta-galactosidase following high-multiplicity infection, but partial recovery of infectivity was achieved by using the fusogenic agent polyethylene glycol. Adsorption of gH-negative virions to cells blocked the adsorption of superinfecting wild-type virus, a result in contrast to that obtained with gD-negative virions (D. C. Johnson and M. W. Ligas, J. Virol. 62:4605-4612, 1988). The simplest conclusion is that gH is required for membrane fusion but not for receptor binding, a conclusion consistent with the conservation of gH in all herpesviruses.

Characterization and sequence analyses of antibody-selected antigenic variants of herpes simplex virus show a conformationally complex epitope on glycoprotein H

Thirteen antigenic variants of herpes simplex virus which were resistant to neutralization by monoclonal antibody 52S or LP11 were isolated and characterized. The antibodies in the absence of complement potently neutralize infectivity of wild-type virus as well as inhibit the transfer of virus from infected to uninfected cells ("plaque inhibition") and decrease virus-induced cell fusion by syncytial strains. The first variant isolated arose in vivo. Of 66 type 1 isolates analyzed from typing studies of 100 clinical isolates, one was identified as resistant to neutralization by LP11 antibody. The glycoprotein H (gH) sequence was derived and compared with those of wild-type and syncytial laboratory strains SC16, strain 17, and HFEM. The sequences were highly conserved in contrast to the diversity observed between gH sequences from herpesviruses of different subgroups. Only four coding changes were present in any of the comparisons, and only one unique coding change was observed between the laboratory strains and the clinical isolate (Asp-168 to Gly). These sequences were compared with those of antigenic variants selected by antibody in tissue culture. Twelve variants were independently selected with antibody LP11 or 52S from parent strain SC16 or HFEM. For each variant, the gH nucleotide sequence was derived and a point mutation was identified giving rise to a single amino acid substitution. The LP11-resistant viruses encoded gH sequences with amino acid substitutions at sites distributed over one-half of the gH external domain, Glu-86, Asp-168, or Arg-329, while the 52S-resistant mutant viruses had substitutions at adjacent positions Ser-536 and Ala-537. One LP11 mutant virus had a point mutation in the gH gene that was identical to that of the clinical isolate, giving rise to a substitution of Asp-168 with Gly. Both LP11 and 52S appeared to recognize distinct gH epitopes as mutant virus resistant to neutralization and immunoprecipitation with LP11 remained sensitive to 52S and the converse was shown for the 52S-resistant mutant virus. This is consistent with previous studies which showed that while the 52S epitope could be formed in the absence of other virus products, virus gene expression was required for stable presentation of the LP11 epitope, and for transport of gH to the cell surface (Gompels and Minson, J. Virol. 63:4744-4755, 1989). All mutant viruses produced numbers of infectious particles that were similar to those produced by the wild-type virus, with the exception of one variant which produced lower yields.(ABSTRACT TRUNCATED AT 400 WORDS)

Phenomenological comparisons of major depression following stroke, myocardial infarction or spinal cord lesions

Patients with major depression admitted to hospital with acute stroke (n = 44), acute myocardial infarction (n = 25), or acute spinal cord injury (n = 12) were examined for differences in their phenomenological presentation of major depression. Depressed stroke patients were found to have significantly higher scores on the syndrome clusters for generalized anxiety and ideas of reference than depressed cardiac or spinal cord injury patients. In addition, significantly more stroke patients met diagnostic criteria for generalized anxiety disorder compared with the other two groups. Although spinal cord injury patients were younger, more likely to be treated with benzodiazepines, and less likely to be treated with beta-blockers, none of these factors distinguished stroke patients with anxious depression from stroke patients with depression only. These findings are consistent with the hypothesis that the etiology of depression following stroke may be different from that associated with myocardial infarction or spinal cord injury.

Autoparathyroidectomy: a case report

This report describes a patient with primary hyperparathyroidism who became spontaneously normocalcaemic preoperatively. This was due to infarction in a parathyroid adenoma. Plasma parathormone (PTH) levels were monitored pre- and postoperatively.

Evidence for A Coagulopathy Related to Endotoxaemia in Patients with Obstructive Jaundice

Animal studies suggest that endotoxaemia may contribute to the disturbances of coagulation in obstructive jaundice. Two groups of patients, 14 controls (C) and 28 jaundiced (J) having pancreatic or biliary surgery were studied prospectively. Endotoxaemia, soluble fibrin (s. f.) by tanned red cell agglutination, FDP and DVT were measured for comparison with outcome of surgery. in group J more complications occurred with 7 deaths and 10 DVT; by comparison, only one death occurred in group C and no DVT, fever or haemorrhage. S. f. was found in none of group C but in 9 of 24 in group J pre-operatively. Presence of s. f. did not influence outcome of surgery. Endotoxaemia and raised FDP were also seen more frequently pre-operatively in group J. of the group J patients 11 had endotoxaemia or FDP before operation and 7 died. An association between endotoxaemia and FDP was shown in both groups and in group J endotoxaemia appears related to s. f. although s. f. and FDP are independent. A coagulopathy, associated with endotoxaemia is present in some jaundiced patients and they fair badly after surgery.

Evidence for a Coagulopathy Related to Endotoxaemia in Patients with Obstructive Jaundice

Animal studies suggest that endotoxaemia may contribute to tbe disturbances of coagulation in obstructive jaundice. Two groups of patients, 14 controls (C) and 28 jaundiced (J) having pancreatic or biliary surgery were studied prospectively. Endotoxaemia, soluble fibrin (s. f.) by tanned red cell agglutination, FDP and DVT were measured for comparison with outcome of surgery. In group J more complications occurred with 7 deaths and 10 DVT; by comparison, only one death occurred in group C and no DVT, fever or haemorrhage.S. f. was found in none of group C but in 9 of 24 in group J pre-operatively. Presence of s. f. did not influence outcome of surgery. Endotoxaemia and raised FDP were also seen more frequently pre-operatively in group J. Of the group J patients 11 had endotoxaemia or FDP before operation and 7 died. An association between endotoxaemia and FDP was shown in both groups and in group J endotoxaemia appears related to s. f. although s, f. and FDP are independent. A coagulopathy associated with endotoxaemia is present in some jaundiced patients and they fair badly after surgery.