The treatment of tardive dyskinesia with baclofen

Thirty-one psychiatric outpatients with tardive dyskinesia (TD) on neuroleptic medication were followed in a double-blind, randomized trial comparing baclofen (30-90 mg per day) to placebo. A repeated measures analysis of variance revealed no statistical difference between the baclofen-treated group and the placebo group for the total Abnormal Involuntary Movement Scale (AIMS) scores. There was a trend (P = 0.09) for an initial improvement, then a worsening of frequency counts across four visits. The authors attempt to explain this finding on the basis of information obtained from animal research.

Plasma prolactin and cortisol concentrations in epileptic patients during the night

Plasma cortisol and prolactin concentrations were determined every four hours, from 8 PM to 8 AM, in 19 epileptic patients during EEG recording of sleep. Data were compared with those obtained from 12 healthy young male volunteers studied under similar conditions. Patients had normal cortisol rhythm, with peak levels at 4 AM or 8 AM and trough at midnight. A sleep-related increase in prolactin concentration was observed in all patients. The range of prolactin concentrations in the patients was also normal. Treatment with valproic acid (ten patients) and frequent abnormal EEG discharges (five patients) did not affect cortisol and prolactin secretion.

Galactorrhea secondary to chest wall surgery in an adolescent

Although nonpuerperal galactorrhea in youth may be a sign of pituitary prolactinoma, the etiology may be benign and extensive neurologic or endocrinologic evaluation and treatment may be unnecessary. An 18-year-old female with an unusual but benign form of transient galactorrhea due to chest wall surgery is reported. It is hypothesized that the sectioning of the intercostal nerves may result in reflex stimulation of hypothalamic centers controlling lactation through the same neural pathways involved in puerperal lactation. The patient experienced galactorrhea for two months and transient amenorrhea. She is asymptomatic without galactorrhea at nine months follow up.

Tardive dyskinesia. A discontinuation study

Twenty-one nonschizophrenic and 12 schizophrenic outpatients with tardive dyskinesia (TD) were followed up for a mean of 12.0 and 8.6 months, respectively, following discontinuation of neuroleptic therapy. Of the 33 patients, only one demonstrated complete reversal of TD. Cumulative survival curves of the length of time to first improvement (reduction in movement ratings by 50% of baseline) did not differ between the two groups. The median time to first improvement was seven months. If a patient can be kept off of a neuroleptic regimen for 18 months, the estimated probability of showing a 50% reduction in movement is 87.2%. In the nonschizophrenic group, depressed mood was negatively correlated with severity of abnormal movements.

Hormonal changes during puberty: V. Transient pubertal gynecomastia: abnormal androgen-estrogen ratios

The plasma profiles of 8 hormones were followed over the course of prepuberty and puberty in 30 adolescent males who developed gynecomastia and 24 who did not. Throughout puberty, ratios of delta 4-androstenedione to estrone (E1) and estradiol (E2) were significantly lower in the gynecomastia group than in the control group. Similarly, ratios of dehydroepiandrosterone-sulfate to E1 and E2 were significantly lower in the gynecomastia group. In contrast, ratios of plasma testosterone to E1 and E2 as well as plasma progesterone and PRL concentrations, were similar in both groups. Because of the adrenal origin of dehydroepiandrosterone and its sulfate, and of peripheral conversion of adrenal androgens to E1 and to E2, it appears that either decreased adrenal production of androgens and/or increased conversion of dehydroepiandrosterone-sulfate and delta 4-androstenedione to estrogens cause transient gynecomastia in adolescent boys.

Perinatal factors that influence the incidence of subependymal and intraventricular hemorrhage in low birthweight infants

A total of 95 preterm infants, delivered consecutively in a perinatal center, over a 9-month period, were studied serially with real-time ultrasound for detection of subependymal/intraventricular hemorrhage (SEH/IVH); all infants were less than or equal to 32-week gestation and/or less than or equal to 1500 gm birthweight. Detailed statistical analysis was carried out to determine the influence of perinatal factors on the occurrence of SEH/IVH. The incidence of SEH/IVH was 34%; severe hemorrhage (Grade III-IV) occurred in only 13%. Gestational age was an important factor associated with SEH/IVH. Thus, the incidence in infants less than or equal to 29-weeks gestation was 45%, whereas in infants greater than 29-weeks gestation age, it was 19% (p less than 0.01). The overall incidence of SEH/IVH in the group which was less than or equal to 29-weeks gestation and delivered by cesarean section was 53%, whereas in those infants delivered vaginally it was 47%. In infants whose gestational age was less than or equal to 29-weeks, the incidence of hemorrhage was 47% if delivered vaginally and presenting as a vertex and 31% if delivered by cesarean section. In infants greater than 29-weeks gestation, the incidence of SEH/IVH was 42% in those delivered by the vaginal vertex route, 5% if presentation was vertex and delivered by cesarean section (p less than 0.05). In infants greater than 29-weeks gestation, cesarean section in vertex presentation decreased the incidence of SEH/IVH when compared with vaginal vertex delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Tardive dyskinesia and plasma homovanillic acid

Using 61 patients with tardive dyskinesia (TD) and 25 normal controls, we explored the possibility that plasma HVA may reflect alterations in central dopamine activity or clinical aspects of TD. There were no significant differences between the two groups in plasma HVA level. Analyses of variance with age and sex as independent variables revealed that the major variance in plasma HVA was accounted for by age in both TD patients (p less than 0.001) and normals (p less than 0.049). Examining the TD patients alone, using multiple regression analysis, revealed that age, neuroleptic dose, and severity of TD accounted for 40% of the variance in plasma HVA in males, with age alone accounting for 28%. By comparison, females showed no association to neuroleptic dose or severity, and age only accounted for 8.9%. When severity of TD was the criterion variable, neuroleptic dose, plasma HVA, and age accounted for 20% of the variance in severity in female TD patients and showed no relationship in males. Possible implications of these differing findings in male and female TD patients are discussed.

The relationship of circulating estradiol to tardive dyskinesia in men and postmenopausal women

In order to assess the relationship between tardive dyskinesia (TD) and baseline circulating concentrations of estradiol, prolactin and homovanillic acid, we studied 43 outpatient men and postmenopausal women on chronic antipsychotic medication. Serum estradiol did not correlate with severity of TD, antipsychotic medication dose, serum prolactin or plasma HVA. Multiple regression analysis indicated a significant relationship between plasma HVA and severity of TD in postmenopausal women. These findings support the hypothesis that estrogen might serve a protective role against neuroleptic-induced striatal dopamine pathology.

Anatomy of the intercostal nerve: its importance during thoracic surgery

Complications from attempts to block the intercostal nerves intraneurally before closure of a thoracotomy have resulted in hypotension with or without spinal block. Placement of a chest tube has resulted in transection of the intercostal nerve. The first of these complications can be avoided by not attempting intraneural block of the nerves intrathoracically. Avoidance of the latter requires careful dissection of the intercostal spaces and identification of the intercostal nerve, as opposed to stab insertion of a chest tube.

Plasma somatomedin-C as a screening test for growth hormone deficiency in children and adolescents

Random plasma somatomedin-C (SM-C) levels were measured in 143 children and adolescents with growth at or below the 5th percentile. 124 patients had short stature due to constitutional delay or genetic predisposition and 19 patients were growth hormone deficient (GHD). When analyzed according to bone age, mean somatomedin-C levels rose gradually with increasing bone age in non-GHD patients, while there was no change with increasing bone age in GHD patients. All patients with SM-C levels less than 0.05 U/ml underwent growth hormone testing to rule out GHD. This criterion resulted in 52% accuracy in identifying non-GHD patients and 100% accuracy in identifying GHD patients. Comparison of the SM-C test with the exercise GH screening test demonstrated the advantage of greater convenience for the SM-C test, and comparable cost effectiveness despite a lower specificity associated with the SM-C test. SM-C levels were not predictive of peak growth hormone response nor could they be used to differentiate constitutional delay of growth and maturation from genetic short stature.

Serum prolactin and tardive dyskinesia

The authors correlated the serum prolactin levels of 19 men with tardive dyskinesia, 29 postmenopausal women with tardive dyskinesia, and 21 men without tardive dyskinesia with the variables age, sex, antipsychotic dosage, and severity of illness. All subjects were taking antipsychotic medication. The prolactin levels of the 14 women with severe tardive dyskinesia were significantly higher than those of the 15 women with mild symptoms. The prolactin levels of the 8 men with severe tardive dyskinesia did not differ from those of the 11 men with mild symptoms. The authors discuss the sex-related association between prolactin and severity of tardive dyskinesia in the context of recent animal studies that have examined the effect of prolactin and estrogens on the striatum.

Celiac plexus block: a roentgenographic, anatomic study of technique and spread of solution in patients and corpses

Techniques for blocking the celiac plexus were evaluated by conventional posteroanterior and lateral x-rays and computed tomography (CT) in 20 patients with intractable pain due to carcinoma of the pancreas and by determining spread of injected dye at the time of autopsy in three corpses. The results showed that (a) the site for insertion of the needles should not be more than 7.5 cm lateral to the spinous process of a lumbar vertebra, (b) needles should be placed bilaterally, (c) the depth to which needles are inserted is greater than previously recommended, and (d) at least 25 ml of solution should be injected through each needle.

Intercostal nerve block: spread of india ink injected to the rib's costal groove

Three and five millilitre of india ink were injected bilaterally into the costal groove of the 9th or 10th ribs of 14 cadavers. The spread was observed and the costal groove of the rib injected was dissected, with the one above and one below. Nunn and Slavin's study (1980) of similar injections in two cadavers indicated that an injection of one costal groove blocked not only the intercostal nerve of that groove, but at least the one above and below it. The present study verified the author's previous report that only the intercostal nerve in the costal groove of the rib injected is anaesthetized.

Intercostal nerve block: a roentgenographic anatomic study of technique and absorption in humans

Roentgenograms of iothalamate meglumine 60% (Conray) injected bilaterally into the intercostal grooves of the ninth or tenth ribs in 30 surgical patients showed extensive spread of the contrast central and peripherally from the site of injection within 30 seconds, with almost complete absorption within 10 minutes 30 seconds. The spread was visualized in two patients for diagnosis using CT (computed tomography) following injection of iothalamate. It was also confirmed by injecting liquid latex into two corpses prior to autopsy. These findings help to explain why the peak plasma level occurs more rapidly and is higher following intercostal nerve block than from other regional nerve blocks when comparable doses are injected. Also, the study revealed that the optimal site for blocking an intercostal nerve is at the angle of the rib and that the optimal needle is one with a short bevel.

Identification of a subgroup of tardive dyskinesia patients by pharmacologic probes

Some patients with tardive dyskinesia fit the cholinergic-dopaminergic imbalance theory, but some do not. In an attempt to study his heterogeneity further, the authors measured the responses of 10 patients with tardive dyskinesia to intravenous challenge doses of drugs that facilitate or inhibit acetylcholine transmission (physostigmine or benztropine, respectively). They then measured the response of these patients to an open outpatient deanol trial. They found that the responses of half of the patients followed the classic theory, 2 responded paradoxically, and 3 responsed inconsistently. They suggest that there is a subgroup of tardive dyskinesia patients who fit the theory but that more research is needed to identify the subgroups who do not.

Spinal anesthesia: bupivacaine compared with tetracaine

A solution of 0.75% bupivacaine (Marcaine) in 8.25% dextrose was compared with a similar solution of tetracaine (Pontocaine), the drug most used for spinal anesthesia in the USA. The study employed a randomized double-blind method and a standardized technique for spinal anesthesia in 435 patients. For perineal and lower extremity surgery, 7.5 mg of the local anesthetic was injected, and for intra-abdominal gynecologic surgery, 12 mg was administered. With the 7.5-mg dose, in only one of 121 patients was anesthesia unsatisfactory when bupivacaine was used; anesthesia was unsatisfactory in 19 of 114 patients when tetracaine was used. With the 12-mg dose, 12 patients given bupivacaine and 14 given tetracaine had unsatisfactory analgesia. With both doses, the motor blockade lasted significantly longer with tetracaine. Epinephrine added to the local anesthetic solution significantly increased the duration of action of both drugs. It also prolonged the duration of postoperative analgesia of tetracaine significantly more than the duration of bupivacaine. Bupivacaine 0.75% in 8.25% dextrose is a safe, reliable local anesthetic solution for spinal anesthesia.

A sensorineural component in chronic otitis media

Traditionally, it has been accepted that conductive deafness involves a breakdown in the mechanical conduction of sound, whilst the cochlea remains unaffected. Over a ten year period, it was noticed that a number of patients, mainly children, displayed a mild, high-tone sensorineural component to their conductive loss, whereas others tested under identical conditions with parallel etiologies did not. A sample of 80 children with chronic otitis media and sensorineural involvement was selected from Prince Henry's Hospital and Alfred Hospital, Melbourne, and was compared with 80 children with the same histories, but whose audiograms did not display any sensorineural involvement. The results of this study indicate a need for further research into: 1. The establishment of an internationally acceptable terminology. 2. Early detection of chronic otitis media. 3. Medical/surgical management. 4. The effects on hearing, caused by fluctuating nature of chronic otitis media. 5. Educational and social management.

The diagnosis of rapid abnormal involuntary movements associated with fluphenazine decanoate

Three patients with low grade tardive dyskinesia developed an acute episode of abnormal involuntary movements after a single injection of fluphenazine decanoate. All three patients had their symptoms relieved after treatment with antiparkinsonian medication. The differential diagnosis of these movements is discussed, and a possible animal model for this phenomenon is described.

Bupivacaine: a review of 11,080 cases

Bupivacaine (Marcaine) hydrochloride, a long-acting local anesthetic drug, was used in concentrations of 0.25, 0.5, or 0.75 percent with and without a vasoconstrictor, in amounts ranging from 25 to over 600 mg, for caudal, epidural (peridural), or peripheral nerve block for 11,080 surgical, obstetrical, diagnostic, or therapeutic procedures. Onset of anesthesia occurred in 4 to 10 minutes and maximum anesthesia in 15 to 35 minutes. Concentrations of 0.25, 0.5, and 0.75 percent consistently produced complete sensory anesthesia of the integumentary and musculoskeletal systems. With 0.25 and 0.5 percent, motor blockade ranged from minimal to complete. In intra-abdominal surgery, only 0.75 percent consistently produced profound muscle relaxation. Fifteen systemic toxic reactions occurred, but no untoward sequelae resulted from them. One inadvertent subarachnoid injection of 110 mg resulted in a total spinal block with an uneventful recovery.

Factors determining dosages of amide-type local anesthetic drugs

The physical status of the patient (sex, age, weight, height, and underlying disease) has been thought to influence the dosage of local anesthetic drugs that can be injected without causing a systemic toxic reaction, but this belief is not supported by statistically significant data. Furthermore, previous studies of plasma levels of bupivacaine and mepivacaine showed no correlation between dosage and physical status, even when maximum dosages recommended by pharmaceutical companies were exceeded. This study of 9,287 regional blocks, using the statistical tests of multiple regression and chi square, substantiates that the occurrence of systemic toxic reactions in adults does not correlate with dosages and/or physical status of the patient when 400 mg or less of bupivacaine, 450 mg or less of etidocaine, or 500 mg or less of mepivacaine is used. Therefore, the study questions the maximum dosages established for certain local anesthetic drugs, as well as the method by which such dosages were established.

Bupivacaine (Marcaine): an evaluation of its tissue and systemic toxicity in humans

In countries other than the U.S.A., dosages of bupivacaine have been limited to 100 mg without epinephrine and 150 mg with epinephrine. A review of 7,688 regional block procedures employing bupivacaine in concentrations of 0.25, 0.5, and 0.75%, and in dosages as high as 600 mg, indicated that such stringent restrictions: (1) are unwarranted, (2) make comparisons with other local anesthetic agents difficult, and (3) are in need of revision.

Studies of anabolic steroids. VI. Effect of prolonged administration of oxandrolone on growth in children and adolescents with gonadal dysgenesis

Twenty-five patients with Turner Syndrome were treated with oxandrolone for six or more months. Mean growth velocity for the first year of treatment was significantly greater than pretreatment control growth velocity. Overall, there was no excessive skeletal maturation. Mean "final" height in nine XO patients (146.4 cm) was significantly greater than mean adult height of an estrogen-treated control group (140.3 cm), while that for five mosaic patients (148.2 cm) was not significantly different from a mean untreated mosaic adult height (145.2 cm).

Abdominal pain and alcohol celiac plexus nerve block

Alcohol celiac plexus nerve blocks were done in 100 patients, of whome 97 had intractable abdominal pain from cancer. In most cases, an initial diagnositc block with bupivacaine was followed by the therapeutic block performed by injecting 50 ml of 50 percent ethyl alcohol. Good to excellent pain relief occurred in 94 percent of patients. Fourteen blocks were repeated for recurrent pain. Life duration ranged from 2 days to 14 months after the block. Complications and side effects were infrequently seen but did include a 10 percent incidence of postural hypotension and 1 case of partial leg paralysis. This block is remarkably safe as well as effective and should be employed more frequently.