Pharmacologic approach to aggression in neuropsychiatric disorders

Aggressive behavior has been associated with numerous neurologic conditions including traumatic brain injury, mental retardation, developmental disorders, Huntington disease, and several dementias. Preclinical and human studies suggest that dysfunction of neural systems involving the brainstem, hypothalamus, amygdala, or prefrontal cortex can give rise to aggression. Several neurochemicals are felt to be relevant to modulation of aggression, including serotonin, dopamine, norepinephrine, GABA, acetylcholine, and androgens. Pharmacologic intervention studies have targeted these systems but have been limited by inconsistent definitions of aggression and a relative paucity of controlled trials. This article briefly reviews studies of neural systems and medication trials relevant to aggression and propose a clinical approach to treatment of patients manifesting aggressive behavior.

Drug related deaths in the community: a preventive role for accident and emergency departments?

Reducing drug related deaths has been identified as a priority by the British government. This study examined the link between drug related deaths in the community and prior contact with local accident and emergency (A&E) services. Most drug related deaths were found among male opioid users in their early 30s who had previously attended the local A&E department. It is suggested that A&E departments have a vital part to play, not only in the acute management but also in the prevention of drug related deaths in the community. Models for primary prevention, liaison and ongoing referral are discussed.

Analysis of several phenolic compounds with potential antioxidant properties in grape extracts and wines by high-performance liquid chromatography-photodiode array detection without sample preparation

A RP-HPLC method that allows the separation of several types of phenolic compounds present in grapes and wines by direct injection of samples, using a binary gradient with solvents free of salts and photodiode array detection is described. Results show that more than 15 different phenolic molecules with antioxidant properties (flavan-3-ols, anthocyanins, cinnamic acid derivatives, flavonol derivatives and trans-resveratrol) may be separated in a single run by direct injection of red wine. The method is also valuable for the analysis of these compounds in white wine and in skins, seeds and pulp extracts of red and white grapes.

Brain attack!--How good is the early management of subarachnoid haemorrhage in accident and emergency departments? South Thames A&E Specialty Sub Committee Audit Group

OBJECTIVES

The aim of this study was to assess the characteristics and audit the management of patients for whom a diagnosis of subarachnoid haemorrhage was made and who were admitted to a neurosurgical centre from an accident and emergency (A&E) department. The objective was to use the results to make recommendations for improving care in this group of patients.

METHODS

Four neurosurgical centres in the South Thames Region provided lists of patients admitted with a diagnosis of subarachnoid haemorrhage during 1997. The medical records and computed tomography of 162 patient episodes from 20 A&E departments were reviewed. The speed of presentation, the provisional diagnosis and the referral patterns were examined. Patient records were audited to investigate what proportion were treated according to established guidelines while in the A&E departments.

RESULTS

63.7% of patients presented to A&E within six hours of ictus and 81.1% within three days. Some 49.2% of patients were seen by a doctor within 30 minutes and 74.7% within one hour. Computed tomography was performed on 18.8% within two hours and only 66.3% within six hours of arrival at the A&E department. Eighteen per cent were treated with nimodipine, 26% with intravenous fluids and 32% were given analgesia before leaving the department. Delays occurred in obtaining computed tomography.

CONCLUSIONS

The management of patients who present to A&E departments with subarachnoid haemorrhage is suboptimal. Improved awareness of the disorder, management by senior A&E staff and clear care pathways could help with management.

Evidence for TeV Emission from GRB 970417a

Milagrito, a detector sensitive to very high energy gamma rays, monitored the northern sky from 1997 February through 1998 May. With a large field of view and a high duty cycle, this instrument was well suited to perform a search for TeV gamma-ray bursts (GRBs). We report on a search made for TeV counterparts to GRBs observed by BATSE. BATSE detected 54 GRBs within the field of view of Milagrito during this period. An excess of events coincident in time and space with one of these bursts, GRB 970417a, was observed by Milagrito. The excess has a chance probability of 2.8x10-5 of being a fluctuation of the background. The probability for observing an excess at least this large from any of the 54 bursts is 1.5x10-3. No significant correlations were detected from the other bursts.

TeV Observations of Markarian 501 with the Milagrito Water Cerenkov Detector

The Milagrito water Cerenkov detector near Los Alamos, New Mexico, was operated as a sky monitor at energies of a few TeV between 1997 February and 1998 May, including the period of the strong, long-lasting 1997 flare of Markarian 501. Milagrito served as a test run for the full Milagro detector. An event excess with a significance of 3.7 sigma from Markarian 501 was observed, in agreement with expectations.

Finite element based predictions of preferred material symmetries in saccular aneurysms

Over the years, various hypotheses have implicated the role of structural instabilities in the expansion of intracranial saccular aneurysms. Recent nonlinear analyses suggest, however, that particular subclasses of aneurysms are structurally stable (in the mechanics sense) and that we must consider different hypotheses. Indeed, based on an ever-increasing database, it appears that aneurysms may well expand via the remodeling of their constituents. Although more data and a kinetics-based formulation of remodeling are needed to examine this hypothesis, we present results from quasistatic finite element analyses of 12 subclasses of lesions that support the remodeling hypothesis. Briefly, we identify regional variations in material symmetry, for a class of noncomplicated axisymmetric lesions subjected to a uniform distension pressure, that minimize local maxima in multiaxial stress and tend to homogenize the stress field. Such symmetries are termed preferred. It is shown that the numerical predictions are consistent with the teleological concept that some intracranial saccular aneurysms will seek to become spherical, since the sphere is an optimal geometry for resisting a distension pressure. To achieve this, however, different subclasses must develop differently. Lesions having an initially large neck:height ratio must increase in height and therefore may seek to become increasingly stiffer circumferentially from the fundus to the neck. Conversely, lesions having an initially small neck:height ratio must increase in breadth and therefore may seek to become increasingly stiffer meridionally from the fundus to the neck. We submit that these results demonstrate the need for a detailed histological examination of regional variations in collagen organization in human lesions, for it is upon data that an analysis of remodeling must be founded.

Incorporation of an (125)I-labeled hexa-iodinated diglyceride analog into low-density lipoprotein and high specific uptake by cells of cervical carcinoma cell lines

The feasibility of using low-density lipoprotein (LDL) to deliver cytotoxic drugs to tumor cells has been explored since the 1980s, when cells of a number of cancer cell lines were found to have higher LDL receptor activity than normal cells. Such differential uptake between tumor and normal cells may provide a unique opportunity to use LDL as a tumor-specific carrier of radiopharmaceuticals for the clinical management of cancer. In this study, an (125)I-labeled hexa-iodinated diglyceride analog, 1, 3-dihydroxypropan-2-one 1,3-diiopanoate (DPIP), was synthesized and incorporated into LDL using a fusion technique. It was found that approximately 500 [(125)I] DPIP molecules were incorporated into each LDL particle. Cells of three human cervical tumor cell lines, HeLa, SiHa and C-33A, were used to examine the cellular uptake of the [(125)I]DPIP-LDL conjugate. It was shown that the [(125)I]DPIP-LDL conjugate was specifically bound to and taken up by cervical tumor cells through an LDL receptor-mediated endocytosis pathway. The results suggest that LDL may be a selective carrier for delivering hydrophobic radiopharmaceuticals to cancer cells and particularly for the diagnosis of cervical tumors.

Abdominal injuries and sport

Serious abdominal injuries resulting from sport are rare. The potential for misdiagnosis is significant and the consequences may be serious. Patients with abdominal pain should be taken very seriously and investigated with appropriate diagnostic equipment. Sporting bodies have a responsibility to address safety within a particular sport and to change the rules where necessary as injury patterns are identified.

Implementation of a two-tier trauma response

OBJECTIVE

To apply a triage tool to patients on their arrival in the emergency department and determine the efficacy and safety of a two-tier trauma response.

DESIGN

Descriptive prospective audit.

SETTING

Principal urban referral hospital that provides a major trauma service.

MATERIALS AND METHODS

The triage tool designated a major trauma or stable trauma response. A major trauma designation mobilised a multidisciplinary team and a stable trauma designation an expedited evaluation by emergency department staff. Chi-square test and Mann-Whitney U test were used to compare major and stable trauma designations. Triage accuracy was evaluated using outcome variables.

MAIN RESULTS

78% of 58 major trauma responses and 30% of 180 stable trauma responses were admitted. The median injury severity score (and interquartile range) of admitted patients was 9.0 (5.0-19.5) for major responses and 5.0 (2.0-9.0) for stable responses. The triage tool had a sensitivity of 65%, specificity of 87%, accuracy (appropriate triage rate) of 82%, undertriage rate of 8% and overtriage rate of 10%.

CONCLUSION

The triage tool adequately distinguished between patients with and without major trauma. Undertriaged patients had timely and appropriate referral for definitive surgical care and had no adverse outcomes.

Performing radiologic gastrostomy or gastrojejunostomy in patients with malignant ascites

OBJECTIVE

We describe our protocol for performing decompression radiologic gastrostomy and gastrojejunostomy in patients with ascites and small-bowel obstruction. We also assess the technical success rate, the complications, and the morbidity and mortality in 45 patients who underwent radiologic gastrostomy.

MATERIALS AND METHODS

Forty-five consecutive patients with ascites associated with metastatic ovarian cancer underwent a radiologic gastrostomy or gastrojejunostomy with gastropexy. Six patients underwent gastrostomy, and 39 patients underwent gastrojejunostomy. Locking catheters were placed using the Seldinger technique after gastropexy in all patients. Paracentesis was performed before gastrostomy or gastrojejunostomy. Additional serial paracenteses were performed after the procedure when reaccumulation of ascites close to the site of gastropexy was detected on follow-up sonography.

RESULTS

Forty-five procedures were attempted. The technical success rate was 97.8%. The complication rate was 15.6%. Three major complications (6.7%) and four minor complications (8.9%) occurred. One procedure-related death (2.2%) occurred 16 days after gastrojejunostomy.

CONCLUSION

Radiologic gastrostomy and gastrojejunostomy can be performed safely in patients with ascites if the patients undergo paracentesis first and if the reaccumulation of ascites is prevented after tube placement. In patients with ascites, gastropexy plays an important role in preventing pericatheter leakage. Ascites and peritoneal carcinomatosis should not be considered contraindications for radiologic gastrostomy or gastrojejunostomy.

Radiographic detection of achalasia: diagnostic accuracy of videofluoroscopy

AIMS

To retrospectively evaluate the accuracy of videofluoroscopy in the diagnosis of achalasia.

MATERIALS AND METHODS

Videofluoroscopic studies of the oesophagus of 53 patients (25 males, 28 females; mean age, 49 years) with manometrically revealed diagnosis of achalasia were retrospectively evaluated. The videofluoroscopic examinations had been carried out with one swallow of low-density barium suspension in the erect and up to three swallows in the prone oblique position. Videofluoroscopically, a diagnosis of achalasia was made in 31 of the patients (58%) with manometrically proven achalasia, of whom only nine had oesophageal dilatation. Non-specific oesophageal motor abnormalities were diagnosed radiographically in 18 patients (34%) and a normal motility in four patients (8%).

CONCLUSION

Videofluoroscopy is a valuable and sensitive technique for the detection of disordered oesophageal motility in achalasia.

A & E nursing and the Internet

The Internet is a relatively new addition to the world of information technology which can be incorporated for use in Accident & Emergency (A & E) nursing, It can provide an information resource and a communications tool for helping A & E nurses in their work. This paper explains the Internet for novices. It discusses the requirements for accessing it and how it can be used by A & E nurses. The aim of the paper is to inform, stimulate and encourage A & E nurses who know little about the Internet to adopt it into their nursing practice.

Alendronate-induced esophagitis: case report of a recently recognized form of severe esophagitis with esophageal stricture--radiographic features

Alendronate sodium, an aminobiphosphonate used primarily to treat osteoporosis in postmenopausal women, is known to cause esophagitis. A 71-year-old woman experienced severe, acute esophagitis and severe stricture of the esophagus due to oral alendronate therapy. Unlike in previous cases, she had taken alendronate for 10 months before the onset of complications and the stricture proved resistant to dilation.

COMPTEL measurements of the omnidirectional high-energy neutron flux in near-earth orbit

On four occasions, twice in 1991 (near solar maximum) and twice in 1994 (near solar minimum), one COMPTEL D1 detector module was used as an omnidirectional detector to measure the high-energy (> 12.8 MeV) neutron flux near an altitude of 450 km. The D1 modules are cylindrical, with radius 13.8 cm and depth 8 cm, and are filled with liquid scintillator (NE213A). The combined flux measurements can be fit reasonably well by a product of the Mt. Washington neutron monitor rate, a linear function in the spacecraft geocenter zenith angle, and an exponential function of the vertical geomagnetic cutoff rigidity in which the coefficient of the rigidity is a linear function of the neutron monitor rate. When pointed at the nadir, the flux is consistent with that expected from the atmospheric neutron albedo alone. When pointed at the zenith the flux is reduced by a factor of about 0.54. Thus the production of secondary neutrons in the massive (16000 kg) Compton Gamma-Ray Observatory spacecraft is negligible. Rather, the mass of the spacecraft provides shielding from the earth albedo.

Fish tank granuloma--a frequently misdiagnosed infection of the upper limb

Five patients attended the accident and emergency (A&E) department with fish tank granuloma caused by an infection with Mycobacterium marinum. All patients had forearm symptoms which were initially misdiagnosed. They were later recognised by the presence of superficial cutaneous lesions in a sporotrichotic distribution. Definitive diagnosis was confirmed by the histological appearances of a biopsy and or culture of the organism. All patients responded to oral minocycline and had uncomplicated recoveries once the diagnosis was established. A&E doctors need to be aware of the possible diagnosis of fish tank granuloma especially when treating forearm infections which have been resistant to antibiotics.