Management of nasal aspergillosis in a dog with a single, noninvasive intranasal infusion of clotrimazole

An 11-year-old, spayed female keeshond was presented for unilateral epistaxis and serous nasal discharge of four weeks duration. Initial nasal radiographs, rhinoscopy, and histopathology suggested severe, destructive lymphoplasmacytic rhinitis. The patient deteriorated while receiving an anti-inflammatory dose of prednisone. A computed tomographic scan of the nose demonstrated a soft-tissue density in both the right nasal cavity and frontal sinus. Samples for histopathology obtained at surgery were diagnostic for nasal aspergillosis. All clinical signs resolved with a single, noninvasive infusion of intranasal clotrimazole and a four-week course of oral itraconazole.

The Center for Epidemiological Studies Depression Scale in older community samples in Indonesia, North Korea, Myanmar, Sri Lanka, and Thailand

Cultural differences in the reporting of depressive symptoms among older people were examined using the Center for Epidemiological Studies Depression (CES-D) scale in five Southeast Asian countries: Indonesia, Korea, Myanmar, Sri Lanka, and Thailand. Previous work in Asian samples--principally North American immigrants--suggested differential functioning of the CES-D. The four-factor solution established in the original studies of the CES-D was replicated for all countries using a confirmatory factor analytic approach. It was, however, demonstrated that little information was lost in considering full-scale scores rather than the four subscales separately. The behavior of the CES-D in older Asian populations was found to be comparable to results obtained in North American and European cultures. Significant somatization of depression in these Asian samples was not found. There appears to be a general factor measuring depressed mood across older populations. The results support the validity of comparing responses on the CES-D across cultures.

Validity of the Composite International Diagnostic Interview (CIDI) psychosis module in a psychiatric setting

This study aimed to test the procedural validity of the psychosis module of the Composite International Diagnostic Interview (CIDI) by comparing it with diagnostic checklists completed by experienced clinicians. Seventy-five subjects were interviewed using the interviewer-administered version of the CIDI. Their clinician(s) then completed diagnostic checklists for DSMIV and ICD10 diagnoses of schizophrenia. Agreement was measured at the diagnostic, criterion and subcriterion levels. The validity standard (diagnostic checklist) was shown to be reliable with interrater agreement between the clinicians for the diagnosis of schizophrenia being excellent (kappa = 0.82 for DSMIV and kappa = 0.71 for ICD10). The agreement between the CIDI and the clinician checklists varied with sensitivities for DSMIV subcriteria ranging from 0.18 (negative symptoms) to 0.93 (bizarre delusions) and specificities ranging from 0.38 (catatonia) to 0.95 (disorganised speech). A similar pattern was found for ICD10 subcriteria: sensitivity varied from 0.19 (neologisms) to 0.90 (persistent delusions) and specificity varied from 0.39 (catatonia) to 0.95 (negative symptoms). The poorest levels of agreement were found for symptoms requiring interviewer judgement. The CIDI showed good agreement with clinician checklist diagnoses when the criteria were based on questions asked of the subjects. When the interviewer was required to make judgement of behaviours, the agreement between the CIDI and the clinician checklists was lower, resulting in overall poor agreement between the CIDI and the clinician checklists. Suggestions for improving the validity of the psychosis module of the CIDI are made.

Evidence of a genetic contribution to functional bowel disorder

OBJECTIVE

Anecdotally, functional bowel disorders (FBD) such as the irritable bowel syndrome appears to cluster in some families, but no studies have investigated the heritability of FBD. We aimed to investigate the influence of heritable factors in FBD.

METHODS

Same sex twin pairs enrolled in the Australian Twin Registry completed a structured interview that included questions related to symptoms consistent with FBD: abdominal pain, diarrhea, constipation, excessive gas or bloating, and nausea. Reasons for the occurrence of each symptom, including their physicians' diagnoses, were recorded. Lisrel 7.16 software was used to fit genetic models following standard procedures.

RESULTS

Of the 686 individual twins from same-sex pairs, 33 (4.8%) had one or more symptoms diagnosed by a medical practitioner as functional bowel disorder. Complete data on this symptom scale was available for 186 monozygotic and 157 same sex dizygotic twin pairs. A model in which 56.9% (95% CI: 40.6-75.9%) of the variance was attributed to additive genetic variance, with the remaining 43.1% attributed to the individual's unique environment, closely fitted the data (chi2=0.01, df=4, p=1.0).

CONCLUSION

Our results suggest that a substantial proportion of the liability for FBD may be under genetic control. Whether this liability is related to the disorder itself or to other potential predisposing factors requires clarification.

Burden of disease. Methods of calculating disability from mental disorder

BACKGROUND

The Global Burden of Disease studies are important because they encompass morbidity as well as mortality. Burden due to morbidity is calculated from incidence, duration and disability. There is a dearth of epidemiological measurements of disability.

METHOD

Data from a quasi-community sample (n = 1364) were analysed. Diagnoses of mental and physical disorders, and reports of disability, were based on established methods.

RESULTS

The disabilities reported in mental and physical disorders were comparable. Disability was correlated with comorbidity. The disability in mental disorders was examined by three methods: pure disorders, main problem and regression. It appears that major depression and substance disorder weights were overestimated, and anxiety disorder weights were underestimated in the Global Burden of Disease studies.

CONCLUSIONS

A method for disentangling the effects of concurrent comorbidity is presented. The size of burden attributed to mental disorders is of potential benefit for funding mental health services, It is important that we get the estimates right.

Long-term outcome of panic disorder and social phobia

The question is addressed as to whether cognitive-behavior treatment delivered as a routine service in a specialist clinic is effective in the long term. Of 124 consecutive patients completing treatment for panic disorder or social phobia, 93 were assessed an average of 2 years following treatment. The treatment produced significant improvement in measures of symptoms, avoidance, and disablement during treatment and further significant improvement during the follow-up. A quarter of participants no longer met diagnostic criteria, had not sought further treatment, and their anxiety had not troubled them since treatment. These findings, although not showing the large treatment effects reported from controlled outcome research, support the effectiveness of cognitive-behavioral interventions in routine care.

Induction of relational schemas: common processes in reasoning and complex learning

Five experiments were performed to test whether participants induced a coherent representation of the structure of a task, called a relational schema, from specific instances. Properties of a relational schema include: An explicit symbol for a relation, a binding that preserves the truth of a relation, potential for higher-order relations, omnidirectional access, potential for transfer between isomorphs, and ability to predict unseen items in isomorphic problems. However relational schemas are not necessarily coded in abstract form. Predictions from relational schema theory were contrasted with predictions from configural learning and other nonstructural theories in five experiments in which participants were taught a structure comprised of a set of initial-state,operator-->end-state instances. The initial-state,operator pairs were presented and participants had to predict the correct end-state. Induction of a relational schema was achieved efficiently by adult participants as indicated by ability to predict items of a new isomorphic problem. The relational schemas induced showed the omnidirectional access property, there was efficient transfer to isomorphs, and structural coherence had a powerful effect on learning. The "learning to learn" effect traditionally associated with the learning set literature was observed, and the long-standing enigma of learning set acquisition is explained by a model composed of relational schema induction and structure mapping. Performance was better after reversal of operators than after shift to an alternate structure, even though the latter entailed more overlap with previously learned tasks in terms of the number of configural associations that were preserved. An explanation for the reversal shift phenomenon in terms of induction and mapping of a relational schema is proposed. The five experiments provided evidence supporting predictions from relational schema theory, and no evidence was found for configural or nonstructural learning theories.

The psychometric properties of the Composite International Diagnostic Interview

The Composite International Diagnostic Interview, or CIDI, is a fully structured interview that maps the symptoms elicited during the interview onto DSM-IV and ICD-10 diagnostic criteria and reports whether the diagnostic criteria are satisfied--nothing more, nothing less. The inter-rater reliability has been demonstrated to be excellent, the test-retest reliability good, and the validity has been demonstrated to be good, given the methodological constraints. The CIDI is available in lifetime and 12-month versions, and in both paper-and-pencil and computer-administered forms. The latter version is suitable for self-administration in cooperative subjects. The CIDI is available in many languages. It is supported by ten centres around the world, which conduct regular training programmes for interviewers. The training programmes are standardised and the training materials are comprehensive. The data from the CIDI is entered into standard data entry and scoring programmes that give as output the diagnostic criteria satisfied. The interviews, the training materials, and the scoring programmes are copyright by the World Health Organization (WHO) and are supervised by an advisory committee on behalf of WHO. That committee and the training centres welcome enquiries from researchers and clinicians who are interested in using the CIDI.

Intimate saboteurs

BACKGROUND

The bariatric patient exists in dynamic relationship with family members and friends who have considerable influence upon the patient and his or her surgical outcome. When family members and friends behave as intimate saboteurs, they attempt to hamper, hurt, or subvert the bariatric patient's goal of achieving and maintaining a healthy body weight. Successful or not, intimate saboteurs provide significant treatment challenges for the patient and the treatment team.

METHODS AND PATIENTS

Patient profiles provide examples of intimate sabotage. The psychological construct of Family Systems Theory is used as a plausible explanation for the sabotage of friends and family.

CONCLUSIONS

Multidisciplinary professionals treating the bariatric patient must be aware of the critical influence of intimate saboteurs and the tactics they use to sabotage. Treatment guidelines recommended by Family Systems Theory are presented as strategies to mitigate the influence of intimate saboteurs.

Disability, outcome and case-mix in acute psychiatric in-patient units

BACKGROUND

Eighteen acute in-patient psychiatric units in Australia funded a syndicate to measure case-mix, disability and outcome of treatment. This syndicate included eight units in public general hospitals, five in stand-alone public psychiatric hospitals and five in private psychiatric hospitals.

METHOD

Up to 100 in-patients admitted consecutively to each hospital (1359 in all) were assigned to a Diagnosis-Related Group (DRG), rated on the Health of the Nation Outcome Scales (HoNOS) and asked to complete the Medical Outcomes Trust Short Form 36 (SF36). These scales were administered again at discharge. Demographic information and length of stay were also recorded. Disability was measured by scores on the HoNOS and SF36 at admission, and outcome was assessed by the change in scores between admission and discharge.

RESULTS

The public hospitals treated significantly more patients with schizophrenia and fewer with affective disorders, and their case load on admission was more disabled, on the whole, than that of the private hospitals. They achieved the same outcome or health gain as the private hospitals, but needed a shorter length of stay to do so. The addition of disability scores to DRG moderately increased the ability to predict length of stay.

CONCLUSIONS

Routine outcome assessment using reliable and valid instruments is practical, and could lead to improvements in the quality of care for psychiatric patients.

Controlled trial of exposure and response prevention in obsessive-compulsive disorder

BACKGROUND

Exposure and response prevention is considered a treatment of choice for obsessive-compulsive disorder (OCD). Yet there have been very few randomised controlled trials employing credible placebo conditions. This study compares exposure and response prevention with a general anxiety management intervention.

METHOD

Eighteen patients meeting DSM-IV criteria for OCD were randomly assigned to either exposure and response prevention or anxiety management. Both treatments involved approximately 15 hours of therapy over a three-week period.

RESULTS

There was a significant reduction in obsessive-compulsive symptoms following treatment with exposure and response prevention, while no change occurred in the control group. This was found to be statistically significant using a composite measure of OCD symptom severity, patient ratings of interference and therapist ratings of symptom severity.

CONCLUSIONS

These findings suggest that the symptom reductions associated with behaviour therapy for OCD are a result of the specific techniques of exposure and response prevention, rather than non-specific aspects of the therapy process. General anxiety management techniques are not effective in the treatment of OCD.

Referred adolescents as young adults: the relationship between psychosocial functioning and personality disorder

OBJECTIVE

To examine the functioning of young adults who had been referred for psychiatric treatment during adolescence.

METHOD

A group of 145 adolescents referred at a mean age of 14 years were interviewed at a mean age of 20 years to ascertain their functioning and whether they suffered from a personality disorder.

RESULTS

Having a personality disorder was associated with poor functioning at follow-up independently of adolescent diagnosis. Antisocial personalities were typified by problems with the law, a poor work record and early cohabitation, while other personality disorders were characterised by social isolation and problems in interpersonal relationships. Poor quality of the family environment and having received treatment during the follow-up period were the only developmental variables associated with poor functioning.

CONCLUSIONS

Developing a personality disorder and having a poor family environment, rather than having an adolescent disorder, appear to be the factors that result in poor functioning in young adults.

Community surveys: the benefits and sacrifices

Community-based research is becoming more important, especially with the introduction of the RDP and the changing role of NGOs. Community surveys are a part of this new research approach. This paper enters the debate around the role and importance of surveys. A case study of a community survey done in Mfuleni by the Western Cape Community Partnership Project will be used to illustrate the points made. Key considerations are raised in terms of the potential for the community survey to be useful. These include the role of the survey in providing information and assisting in the process of the development of the project as a whole. In addition the cost effectiveness plus the ethical and political dimensions are considered. In the course of the survey important lessons were learned that could benefit others also doing research of this type. Issues raised include the importance of the presence of specific research skills being part of the team throughout the project, the importance of full negotiation of access, being clear in terms of objectives and the questions to be asked, sampling issues, problems of questions demanding memory recall, community participation and spreading of skills, and the dissemination of results.

Nasosinusal fungal granuloma--clinical profile

Fifty cases of nasosinusal fungal granuloma were admitted under the ENT Department in a teaching tertiary care hospital in India during a thirteen-year period. Aspergillus species was found to be the most common causative fungus (29) followed by Mucorales (14), Entomophthorales (5) and Fusarium (2) species. There were 13 cases of non-invasive and 16 cases of invasive variants of Aspergillosis. In spite of intravenous amphotericin B therapy and radical surgical debridement, 81% in the invasive group showed relapse and required prolonged oral antifungal drugs and multiple surgical procedures. Among the 14 cases of Mucormycosis, all of the 10 cases who received intravenous amphotericin B and radical surgery showed complete recovery with no relapse over a period of 2 to 10 years. This is contrary to earlier published reports which suggest poor prognosis. The entomophthoromycosis received oral steroids and cotrimoxazole, and oral potassium iodide or intravenous amphotericin in case of relapse. Both the cases of Fusariosis recovered completely with oral ketoconazole.

The Post-surgical Treatment of the Bariatric Patient: Helping the Patient Succeed

BACKGROUND: A psychological profile of the average bariatric patient demonstrates psychopathology that may contribute to patient noncompliance with post-surgical treatment guidelines. METHODS AND RESULTS: Patient psychopathology is analyzed with regard to noncompliance and its contribution to poor surgical outcome. The interpersonal process approach is reviewed as a psychotherapeutic framework that provides interventions to patient psychopathology. CONCLUSIONS: Treatment of patient psychopathology with the interpersonal process approach encourages post-surgical compliance and helps patients succeed.

Comorbidity and the general neurotic syndrome

The observation that people with an anxiety or depressive disorder also have an increased likelihood of having had other anxiety or depressive disorders in their lifetime means either that the separate causes of these disorders have aggregated, much more than chance would allow, or that some general vulnerability factor has made them liable to each and all of the disorders they report. In this paper, three separate sources of information-symptoms occurring in the general population, disorders occurring in the general population, and disorders occurring in patients who have sought treatment-are reviewed. In all three domains of information, a general vulnerability factor, associated with personality trait measures of high trait anxiety and poor coping, emerges as a principal cause of these symptoms or disorders, and accounts for the majority of the variation in the comorbidity of symptoms or disorders. This vulnerability factor is shown to be under substantial gentic control. Nevertheless it can be modified by appropriate treatment, and prevention strategies exist to reduce the incidence of the anxiety and depressive disorders.

Do specific anxiety disorders show specific drug problems?

OBJECTIVE

Comorbidity between anxiety and substance use disorders was examined. The hypothesis was tested that social phobics may report greater problem alcohol use (if alcohol is used to manage social anxiety) while problem use of sedative-hypnotics may be greater in people with panic (who may be over-prescribed anxiolytics because they repeatedly seek medical assistance).

METHOD

Self-reported lifetime rates of drug and alcohol problems were assessed with the computerised Diagnostic Interview Schedule-Revised. Subjects were 146 consecutive patients treated for panic disorder (with and without agoraphobia) and social phobia at the Clinical Research Unit for Anxiety Disorders.

RESULTS

High prevalences of alcohol problems (three times that expected) and problem use of sedative hypnotics (eight times that expected) were found in all diagnoses. Social phobics exhibited comparatively high rates of problem alcohol use, but no diagnostic specific differences in problem sedative-hypnotic use were found.

CONCLUSION

Routine screening for drug and alcohol problems is necessary for patients with anxiety disorders.

Change in danger cognitions in agoraphobia and social phobia during treatment

Cognitive theories of anxiety emphasise the differences in anxious concerns and symptomatology across the anxiety disorders. The nature and extent of danger appraisal in social phobics and agoraphobics was examined and compared with that of a non-phobic group of adult stutterers. All groups were measured before, during and after treatment. Results showed that the form of danger appraisal was related to the fears exhibited, reductions in the particular appraisals of danger were associated with reductions in specific fears, and specific patterns of danger appraisal emerged. Agoraphobics' concerns with physical and loss of control danger normalized during treatment. Despite considerable and significant improvement, social phobics continued to have social evaluation danger scores significantly higher than the control group at the end of treatment. While cognitive behavioural therapy does change relevant fear cognitions, it appears that the intransigence of social phobic concerns about negative evaluations may require extra time and/or therapy.

Personality disorder in obsessive compulsive disorder: a controlled study

In order to assess Axis II pathology in Obsessive Compulsive Disorder patients as compared to other anxiety disorder patients, the Personality Disorder Examination was administered to 258 anxiety disorder patients. In contrast to a number of recent reports, a low rate of personality disorder diagnoses were found in the OCD sample as well as the anxiety disorder control subjects. The findings of the current investigation are discussed in terms of state-trait confounding.

Comorbidity in the anxiety disorders: the use of a life-chart approach

Findings of comorbidity across the anxiety and depressive disorders have implications for aetiology, diagnosis and treatment. This paper describes a method to assess one aspect of the relationship between comorbid disorders: the degree to which one illness experience is believed to be caused by the earlier experience of a different illness. The life-chart method involves the use of a semi-structured interview to document the lifetime course of disorders. The method was reliable in a sample of patients treated at a specialized treatment unit for anxiety disorders. Patients fell into three major groupings: those with one disorder only (19%); those who fulfilled criteria for two or more disorders, but with one disorder primary and other disorders secondary to it (55%); and those who fulfilled criteria for two or more independent disorders (26%).