Comparison of the incidence of schizophrenia in rural Dumfries and Galloway and urban Camberwell

BACKGROUND

Being born or living in urban areas is associated with high rates of schizophrenia. However, few studies have compared the incidence in urban/rural areas using the same methodology.

AIMS

To compare service-based incidence rates for schizophrenia in rural Dumfries and Galloway in south-west Scotland with urban Camberwell in south-east London.

METHOD

Using Research Diagnostic Criteria diagnoses from the OPCRIT computer algorithm, we compared the incidence of schizophrenia over 12 years (1979-1984 and 1992-1997) using indirect standardisation techniques and Poisson regression modelling.

RESULTS

The incidence was 61% higher in urban Camberwell than in rural Dumfries and Galloway (standardised incidence ratio (SIR)=1.61; 95% CI=1.42-1.81). There was no difference in incidence when we compared the White population in Camberwell with Dumfries and Galloway (SIR=1.12; 95% CI=0.86-1.43).

CONCLUSIONS

The incidence of schizophrenia in urban Camberwell was higher than that in rural Dumfries and Galloway; the high incidence of non-Whites in Camberwell largely explains the urban/rural difference.

A real-time interface for a formant speech synthesizer

This paper describes a multi-parametric user interface based around the Musical Instrument Digital Interface (MIDI) Creator system developed at York which provides MIDI data in response to changing pressures on five strain gauge sensors to control the fundamental frequency, first three formants and the overall amplitude of synthesized speech. Vocal synthesis is achieved by means of a freely available time domain formant synthesis system running on a standard PC compatible machine. The result is a novel hand-controlled speech synthesizer which is not command/phoneme based, but is rather more like a continually controlled musical instrument where the speech sounds are shaped in real-time.

Zoonotic infections from pets. Understanding the risks and treatment

As much as we hate to admit it, even the gentlest of our friendly pets can harbor harmful pathogens, and although the fact is not widely known, pet-associated infections can significantly affect the health of humans. In this article, Dr Morrison focuses on pets and their accompanying potential zoonoses, outlining how these diseases can be transmitted to humans and how the infections are treated. Special attention is paid to rabies and toxoplasmosis, which have attained particular notoriety over time.

Adrenocortical carcinoma with cerebral metastasis in a child: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Adrenocortical carcinoma (ACC) is rare in the pediatric population, and brain metastasis seldom occurs.

CLINICAL PRESENTATION

The authors report a case of metastatic ACC to the brain in a 9-year-old patient who had an adrenal cortex neoplasm removed at 4 years of age, and was free of symptoms for 5 years. Two weeks before admission she complained of blurred vision in both eyes.

INTERVENTION

Examination revealed bilateral papilledema, and a Magnetic Resonance Imaging (MRI) of the brain revealed a mass in the left lateral ventricle with extensive vasogenic edema and hydrocephalus. The tumor was removed, and histopathologic examination demonstrated metastatic ACC.

CONCLUSION

Although ACC is a rare neoplasm it must be considered in the differential diagnosis of cerebral lesions in patients with a history of this tumor. Periodic long-term brain imaging is suggested as part of the follow up in patients with adrenocortical neoplasms.

Reforming the core clerkship in internal medicine: the SGIM/CDIM Project. Society of General Internal Medicine/Clerkship Directors in Internal Medicine

Dramatic changes in health care have stimulated reform of undergraduate medical education. In an effort to improve the teaching of generalist competencies and encourage learning in the outpatient setting, the Society of General Internal Medicine joined with the Clerkship Directors in Internal Medicine in a federally sponsored initiative to develop a new curriculum for the internal medicine core clerkship. Using a broad-based advisory committee and working closely with key stakeholders (especially clerkship directors), the project collaborators helped forge a new national consensus on the learning agenda for the clerkship (a prioritized set of basic generalist competencies) and on the proportion of time that should be devoted to outpatient care (at least one third of the clerkship). From this consensus emerged a new curricular model that served as the basis for production of a curriculum guide and faculty resource package. The guide features the prioritized set of basic generalist competencies and specifies the requisite knowledge, skills, and attitudes/values needed to master them, as well as a list of suggested training problems. It also includes recommended training experiences, schedules, and approaches to faculty development, precepting, and student evaluation. Demand for the guide has been strong and led to production of a second edition, which includes additional materials, an electronic version, and a pocket guide for students and faculty. A follow-up survey of clerkship directors administered soon after completion of the first edition revealed widespread use of the curricular guide but also important barriers to full implementation of the new curriculum. Although this collaborative effort appears to have initiated clerkship reform, long-term success will require an enhanced educational infrastructure to support teaching in the outpatient setting.

Phase I and pharmacokinetic trial of weekly oral fluorouracil given with eniluracil and low-dose leucovorin to patients with solid tumors

PURPOSE

Fluorouracil (5-FU) given as a weekly, high-dose 24-hour infusion is active and tolerable. We evaluated an oral regimen of eniluracil (which inactivates dihydropyrimidine dehydrogenase [DPD]), 5-FU, and leucovorin to simulate this schedule.

PATIENTS AND METHODS

Patients received a single 24-hour infusion of 5-FU (2,300 mg/m(2) on day 2) with leucovorin (15 mg orally [PO] bid on days 1 through 3) to provide reference pharmacokinetic data. Two weeks later, patients began treatment with eniluracil (20 mg) and leucovorin (15 mg) (PO bid on days 1 through 3) and 5-FU (10 to 15 mg/m(2) PO bid on day 2).

RESULTS

Dose-limiting toxicity (diarrhea, neutropenia, and fatigue) was seen with 5-FU 15 mg/m(2) PO bid on day 2 given weekly for either 6 of 8 weeks or 3 of 4 weeks, whereas five of seven patients tolerated 5-FU 10 mg/m(2) PO bid given weekly for 3 of 4 weeks. Eniluracil led to a 35-fold reduction in 5-FU clearance. Fluoro-beta-alanine, a 5-FU catabolite, was not detected in plasma during oral 5-FU-eniluracil therapy. DPD activity was markedly suppressed in all patients during eniluracil therapy; the inactivation persisted after the last eniluracil dose; percentages of baseline values were 1.8% on day 5, 4.5% on day 12, and 23.6% on day 19.

CONCLUSION

The recommended oral dosage of 5-FU (10 mg/m(2) PO bid) given with eniluracil and leucovorin is approximately 115-fold lower than the reference dosage for 24-hour infusional 5-FU. This difference is greater than expected given the reduction in 5-FU clearance. DPD inactivation persisted for several weeks after completion of eniluracil therapy.

Nithsdale Schizophrenia Surveys. 20. Cognitive function in a catchment-area-based population of patients with schizophrenia

BACKGROUND

Cognitive deficits are a core aspect of schizophrenia but there has been no study of cognitive function in a catchment-area-based population of patients with schizophrenia.

AIMS

To assess cognitive function in a population of patients with schizophrenia, and relate it to community functioning.

METHOD

All patients with schizophrenia in Nithsdale, south-west Scotland, were identified (n = 182). Measures of assessment were: National Adult Reading Test (NART), Mini-Mental State Examination (MMSE), Rivermead Behavioural Memory Test (RBMT), Executive Interview (EXIT), FAS Verbal Fluency and Health of the Nation Outcome Scales (HoNOS).

RESULTS

We assessed 138 patients, mean age 48 years (standard deviation (s.d.) 15). Only 14% were in-patients. The mean premorbid IQ as assessed by NART was 98 (s.d. 14); 15% of patients had significant global cognitive impairment (MMSE); 81% had impaired memory (RBMT); 25% had executive dyscontrol (EXIT); and 49% had impaired verbal fluency (FAS). Scores on the functional impairment sub-scale of HoNOS correlated with all measures of cognitive impairment.

CONCLUSIONS

Cognitive dysfunction is pervasive in a community-based population of patients with schizophrenia.

Development of a case-based integrated nutrition curriculum for medical students

The Nutrition Education and Prevention Program at the University of Pennsylvania School of Medicine is a successful program that can be used as a model for the development and implementation of a case-based nutrition curriculum across the 4-y medical school experience. This article gives a broad overview of the development, implementation, evaluation, and dissemination processes used by the Nutrition Education and Prevention Program administration and core faculty group at the University of Pennsylvania School of Medicine. Beginning in 1990, the nutrition curriculum was initiated with the assistance of several funding sources. The program was structured using a multidisciplinary faculty group of physicians and registered dietitians from multiple departments, centers, and institutes. The outcome of this process is a textbook, Medical Nutrition and Disease, currently required by numerous medical schools, residency programs, and other health professional programs across the nation. With the use of data from the Association of American Medical Colleges All Schools Survey of Graduating Medical Students, perceptions of the adequacy of nutrition education were tracked over time. In 1991, 80% of University of Pennsylvania medical students felt that nutrition coverage was inadequate compared with 10% of medical students in 1998, a significant change resulting from the nutrition program's effect. The University of Pennsylvania School of Medicine has developed and implemented a successful nutrition curriculum, despite national trends. The case-based integrated curricular model presented in Medical Nutrition and Disease and on our Web site, www.med.upenn.edu/nutrimed, can be used by medical institutions and other health professionals.

Epilepsy surgery in children with tuberous sclerosis complex: presurgical evaluation and outcome

PURPOSE

Children with tuberous sclerosis complex (TSC) benefit from excisional surgery if seizures can be localized to a single tuber. We evaluated the role of noninvasive studies to localize the epileptogenic tuber/region (ET/R) and the outcome of focal resection.

METHODS

We identified 21 children with TSC, ages 3 months to 15 years (mean 4.8 years). All had video-(electroencephalogram) EEG and magnetic resonance imaging (MRI) scans, and 18 also had ictal single photon emission-computed tomography (SPECT) studies. An ET/R was localized in 17 patients. Thirteen patients underwent resection guided by intraoperative electrocorticography (n = 7) or subdural monitoring (n = 6).

RESULTS

Interictal EEG revealed a principal spike focus (PSF) that corresponded to the ET/R in 14 children. In seven, PSFs occurred in rhythmic runs. PSFs were not observed remote from the ET/R. Focal polymorphic slowing and attenuation occurred in the region of the PSF in 11 patients. Sixteen patients demonstrated an ictal focus corresponding to the ET/R. Ictal SPECT revealed focal hyperperfusion correlating with the ET/R in 10 patients. Although the MRIs in all children revealed multiple tubers, the ET/R corresponded to a large discrete tuber in 8 patients and a calcified tuber in 13 patients. Patchy calcified tubers were also seen elsewhere in six patients. At a mean follow-up of 26 months, 9 of the 13 children who underwent surgery were seizure-free, one had greater than 75% reduction in seizures, two were unchanged, and one was lost to follow-up. New seizures developed in one child from a contralateral tuber.

CONCLUSIONS

Surgical resection of an ET/R alleviates seizures in most children with TSC and intractable epilepsy. The scalp EEG and MRI help define the ET/R and improve case selection when ictal SPECT is nonlocalizing.

Platinum-group elements: quantification in collected exhaust fumes and studies of catalyst surfaces

Automotive catalytic converters, in which Pt, Pd and Rh (platinum-group elements; PGEs) are the active components for eliminating several noxious components from exhaust fumes, have become the main source of environmental urban pollution by PGEs. This work reports on the catalyst morphology through changes in catalyst surface by scanning electron microscopy/energy dispersive X-ray spectroscopy (SEM/EDX) and laser-induced breakdown spectrometry (LIBS) from fresh to aged catalytic converters. The distribution of these elements in the fresh catalysts analysed (Pt-Pd-Rh gasoline catalyst) is not uniform and occurs mainly in a longitudinal direction. This heterogeneity seems to be greater for Pt and Pd. PGEs released by the catalysts, fresh and aged 30,000 km, were studied in parallel. Whole raw exhaust fumes from four catalysts of three different types were also examined. Two of these were gasoline catalysts (Pt-Pd Rh and Pd-Rh) and the other two were diesel catalysts (Pt). Samples were collected following the 91,441 EUDC driving cycle for light-duty vehicle testing. The results show that at 0 km the samples collected first have the highest content of particulate PGEs and although the general tendency is for the release to decrease with increasing number of samples taken, exceptions are frequent. At 30,000 km the released PGEs in gasoline and diesel catalysts decreased significantly. For fresh gasoline catalysts the mean of the total amount released was approximately 100, 250 and 50 ng km(-1) for Pt, Pd and Rh, respectively. In diesel catalysts the Pt release varied in the range 400-800 ng km-1. After ageing the catalysts up to 30,000 km, the gasoline catalysts released amounts of Pt between 6 and 8 ng km(-1), Pd between 12 and 16 ng km(-1) and Rh between 3 and 12 ng km(-1). In diesel catalysts the Pt release varied in the range 108-150 ng km(-1). The soluble portion of PGEs in the HNO3 collector solution represented less than 5% of the total amount for fresh catalysts. For 30,000 km the total amount of soluble PGEs released was similar or slightly higher than for 0 km.

Evaluation of a national curriculum reform effort for the medicine core clerkship

BACKGROUND

In 1995, the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) developed and disseminated a new model curriculum for the medicine core clerkship that was designed to enhance learning of generalist competencies and increase interest in general internal medicine.

OBJECTIVE

To evaluate the dissemination and use of the resulting SGIM/CDIM Core Medicine Clerkship Curriculum Guide.

DESIGN

Survey of internal medicine clerkship directors at the 125 medical schools in the United States.

MEASUREMENTS AND MAIN RESULTS

The questionnaire elicited information about the use and usefulness of the Guide and each of its components, barriers to effective use of the Guide, and outcomes associated with use of the Guide. Responses were received from 95 clerkship directors, representing 88 (70%) of the 125 medical schools. Eighty-seven (92%) of the 95 respondents were familiar with the Guide, and 80 respondents had used it. The 4 components used most frequently were the basic generalist competencies (used by 83% of those familiar with the Guide), learning objectives for these competencies (used by 83%), learning objectives for training problems (used by 70%), and specific training problems (used by 67%); 74% to 85% of those using these components found them moderately or very useful. The most frequently identified barriers to use of the Guide were insufficient faculty time, insufficient number of ambulatory care preceptors and training sites, and need for more faculty development. About 30% or more of those familiar with the Guide reported that use of the Guide was associated with improved ability to meet clerkship accreditation criteria, improved performance of students on the clerkship exam, and increased clerkship time devoted to ambulatory care.

CONCLUSION

This federally supported initiative that engaged the collaborative efforts of the SGIM and the CDIM was successful in facilitating significant changes in the medicine core clerkship across the United States.

Schizophrenia is not disappearing in south-west Scotland

BACKGROUND

Recent work has reported a decline in the incidence of schizophrenia, but it is unclear if these findings reflect a true decrease in its incidence or are an artefact arising from methodological difficulties.

AIMS

To take account of these methodological difficulties and report service-based incidence rates for schizophrenia in Dumfries and Galloway in south-west Scotland for 1979-98.

METHOD

Using both clinical diagnoses and diagnoses generated from the Operational Checklist for Psychotic Disorders (OPCRIT) computer algorithm for ICD-10 and DSM-IV schizophrenia, we measured change in the incidence rates over time. We used indirect standardisation techniques and Poisson models to measure the rate ratio linear trend.

RESULTS

There was a monotonic and statistically significant decline in clinically diagnosed schizophrenia. The summary rate ratio linear trend was 0.77. However, using OPCRIT-generated ICD-10 and DSM-IV diagnoses, there was no significant difference over time.

CONCLUSIONS

OPCRIT-generated consistent diagnoses revealed no significant fall in the incidence of schizophrenia. Changes in diagnostic practice have caused the declining rates of clinically diagnosed schizophrenia in Dumfries and Galloway.

Prenatal diagnosis of airway compromise: EXIT (ex utero intra-partum treatment) and foetal airway surgery

Four cases of potential airway obstruction diagnosed in the early antenatal period are presented. Their management is outlined, and the need for a multidisciplinary team approach to these problems is highlighted. The experience of the ex-utero intrapartum treatment (EXIT) procedure is presented, and the first attempt at intra-uterine tracheal surgery is introduced.

Nithsdale schizophrenia surveys 21: a longitudinal study of National Adult Reading Test stability

BACKGROUND

The stability of the National Adult Reading Test (NART) as a measure of pre-morbid intelligence in schizophrenia has not yet been satisfactorily established despite the widespread use of the NART in schizophrenia research.

METHOD

We examined NART stability in a diverse group of 45 schizophrenic patients in a prospective longitudinal study over 6.5-7.5 years.

RESULTS

The results showed that NART performance does not decline significantly with increasing duration of schizophrenic illness and that test-retest reliability, even over 6.5-7.5 years, is extremely high.

DISCUSSION

Our results provide the necessary evidence that the NART can be used as a stable measure of pre-morbid intelligence in schizophrenia.

Predictors of outcome in pediatric epilepsy surgery

OBJECTIVE

To determine the correlation between pre- and perioperative variables on the outcome of children undergoing focal resections for medically intractable partial epilepsy.

METHODS

Retrospective analysis of pre- and perioperative variables in a cohort of 75 patients younger than 12 years of age who underwent excisional surgery and had at least 1 year of follow-up. Outcome, measured by postoperative seizure frequency, was analyzed as a function of age at seizure onset, duration of epilepsy, presence of cognitive impairment, lobe of seizure origin, presence of a lesion, histopathology, and completeness of resection. Completeness of resection was defined on the basis of excising both the entire structural lesion if present and the region revealing prominent interictal and ictal abnormalities on intracranial EEG.

RESULTS

Seventy-seven percent of patients had good outcomes (class 1 or 2), and 59% were seizure-free. Lesional status, site of resection, and pathologic diagnoses were not significant predictors of outcome except for in multilobar resection, for which overall outcome was relatively poor (44% class 3 or 4; 22% seizure-free). Completeness of resection was the only significant predictor of good outcome (p < 0.001), with 92% of patients who underwent complete resection of the epileptogenic zone achieving good outcome compared with 50% of patients who had incomplete resections.

CONCLUSION

In this series of pediatric patients, complete resection of the lesion and the electrographically abnormal region was the main determinant of outcome after focal resections. Except for multilobar resections, other factors examined in this study did not significantly influence postoperative seizure prognosis and should not influence candidate selection for the surgical process.

Phase I and pharmacologic study of irinotecan administered as a 96-hour infusion weekly to adult cancer patients

PURPOSE

We conducted a phase I and pharmacologic study of a weekly 96-hour infusion of irinotecan to determine the maximum-tolerated dose, define the toxicity profile, and characterize the clinical pharmacology of irinotecan and its metabolites.

PATIENTS AND METHODS

In 26 adult patients with solid tumors, the duration and dose rate of infusion were escalated in new patients until toxicity was observed.

RESULTS

In 11 patients who were treated with irinotecan at 12.5 mg/m(2)/d for 4 days weekly for 2 of 3 weeks, dose-limiting grade 3 diarrhea occurred in three patients and grade 3 thrombocytopenia occurred in two patients. The recommended phase II dose is 10 mg/m(2)/d for 4 days given weekly for 2 of 3 weeks. At this dose, the steady-state plasma concentration (Css) of total SN-38 (the active metabolite of irinotecan) was 6.42 +/- 1.10 nmol/L, and the Css of total irinotecan was 28.60 +/- 17.78 nmol/L. No patient experienced grade 3 or 4 neutropenia during any cycle. All other toxicities were mild to moderate. The systemic exposure to SN-38 relative to irinotecan was greater than anticipated, with a molar ratio of the area under the concentration curve (AUC) of SN-38 to irinotecan of 0.24 +/- 0.08. One objective response lasting 12 months in duration was observed in a patient with metastatic colon cancer.

CONCLUSION

The recommended phase II dose of irinotecan of 10 mg/m(2)/d for 4 days weekly for 2 of 3 weeks was extremely well tolerated. Further efficacy testing of this pharmacologic strategy of administering intermittent low doses of irinotecan is warranted.

A pilot study of interferon alpha-2a, fluorouracil, and leucovorin given with granulocyte-macrophage colony stimulating factor in advanced gastrointestinal adenocarcinoma

We reported previously that the addition of recombinant Escherichia coli human granulocyte-macrophage colony stimulating factor (GM-CSF) to a 5-fluorouracil (5-FU) and leucovorin (LV) regimen seemed to ameliorate diarrhea and permit increased 5-FU dose intensity (J. L. Grem et al., J. Clin. Oncol., 12: 560-568, 1994). We then tested the effect of GM-CSF given with a more toxic regimen of 5-FU/LV/IFN-alpha (IFN alpha-2a). Thirty-one patients with a good performance status and no prior chemotherapy for systemic disease received IFN alpha(-2a (5 MU/m2 s.c., days 1-7), 5-FU (370 mg/m2 i.v., days 2-6), LV (500 mg/m2 i.v., days 2-6), and GM-CSF (Saccharomyces cerevisiae 250 microg/m2 s.c., days 7-18) every 3 weeks. Toxicities and 5-FU dose intensity were compared with that observed in our prior Phase II trial with 5-FU/LV/IFN alpha-2a (J. L. Grem et al., J. Clin. Oncol., 11: 1737-1745, 1993). In comparison with the prior Phase II study, the WBC and granulocyte nadirs in the present trial were significantly higher. When trends in toxicity grades for all cycles were compared, stratifying for 5-FU dose, the incidence and severity of mucositis, skin rash, WBC toxicity, and granulocyte toxicity were significantly lower in the present trial, whereas nausea/vomiting and fatigue were significantly worse. The delivered 5-FU dose intensity for all cycles of therapy appeared to be significantly higher in the present trial. Six of 28 evaluable patients had a partial response (21.4%), and 13 (46%) had stable disease for > or =12 weeks. Despite treatment-related toxicity, patient quality of life did not worsen during the study. No correlation was observed between thymidylate synthase content in primary tumor specimens and response, time to treatment failure, or survival. The addition of GM-CSF appeared to decrease the severity of leukopenia, granulocytopenia, mucositis, and skin rash when compared with our prior experience with this regimen of 5-FU/LV/IFN alpha-2a, at the cost of greater nausea/vomiting and fatigue. The potential impact of increased 5-FU dose intensity on clinical response, however, remains to be determined.

Unique clinical presentation of pediatric shunt malfunction

INTRODUCTION

A cerebrospinal fluid (CSF) shunt is the primary treatment for most etiologies of hydrocephalus in the pediatric population. Malfunction of the shunt may present with unique symptoms and signs. This retrospective review investigates the presenting signs and symptoms of pediatric patients with shunt malfunction. Clinical

MATERIAL AND METHOD

One-hundred-and-thirty CSF diversion procedures were performed at two affiliated pediatric hospitals over a 2-year period. Seventy consecutive cases of CSF shunt revision were reviewed. These 70 operations were performed on 65 patients. Their medical records and radiographic studies were reviewed, and supplemented with a telephone interview to obtain a minimum of 3 months follow-up.

RESULTS

The 65 patients' age ranged from 3 months to 16 years. The original etiology of the hydrocephalus was Chiari II malformation in 17, idiopathic in 15 and intraventricular hemorrhage in 10, neoplasm in 8 patients and meningitis in 5 patients. The most frequent presenting symptoms were headache (39 admissions), nausea/vomiting (28) and drowsiness (21). Seven Chiari patients (41%) presented with neck pain, 2 (12%) presented with lower cranial nerve palsy, and 2 (12%) presented with symptomatic syrinx, complaints not reported by non-Chiari patients (p < 0.01, chi2 analysis). Four myelodysplastic patients presented with a new-onset or recurrent seizure episode, which was significantly more frequent than in nonmyelodysplastic patients (p < 0.05, chi2 analysis). On examination, increased head circumference was noted in 17 patients. Parinaud's syndrome was noted more prominently in patients with a history of intracranial neoplasm (4 of 8 cases) than in patients with nonneoplastic diseases (2 of 62 cases; p < 0.05, chi2 analysis). Other interesting presenting signs were pseudocyst (2), syringomyelia (2), hemiparesis (2) and Parkinson-like rigidity (2).

CONCLUSION

Pediatric shunt malfunction generally presents with headache, nausea/vomiting, altered mental status, increased head circumference and bulging fontanelle. Other less frequent but unique presenting signs and symptoms, such as neck pain, syringomyelia and lower cranial nerve palsy in the myelodysplastic population, and Parinaud's syndrome in patients with a history of intracranial neoplasm are frequently associated with shunt malfunction and should prompt a radiographic workup.