Psychiatric presentations of epilepsy

The abnormal neuronal excitability underlying seizure disorders may alter behavior. Behavioral alterations associated with epilepsy can occur during the ictal period, especially in patients who suffer partial seizures of temporal or frontal lobe origin, or during the interictal period in the setting of chronic temporolimbic seizure discharges. We use case descriptions to illustrate behavioral presentations of epilepsy that resemble primary psychiatric illnesses, including schizophrenic psychoses, mood disorders, panic disorder, and dissociative disorders. The varied secondary psychiatric syndromes produced by epilepsy are elucidated by a consideration of normal functions of temporal and frontolimbic structures. The clinical pictures provide clues to the causes of primary psychiatric disorders.

The management of chronic somatisation

'Somatisation' is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied. In some patients this process becomes chronic (in excess of six months). Special skills and strategies are required by non-psychiatrists to manage these patients, for whom the acceptance of psychiatric treatment should be facilitated. When taking the history, doctors should be aware of psychosocial cues; thereafter they should be consistent and unambiguous in their management. An agenda should be set early on, with limits on investigations. Failure to manage this group of patients is costly, and further intervention studies are required not only to reduce health service and other costs, but also to relieve the non-monetary burden of physical and psychosocial disability on patients and their relatives.

Physicians know how to be good educators too: a comparison of the patient problem solving process and the instructional design process

Education should be viewed as one of the important roles of a physician. Yet, because physicians generally are not trained to be educators, many instructional sessions, lectures and workshop presentations are ineffective because the instructional design process has been ignored. While not a substitute for professional education courses, physicians can use knowledge of the patient problem solving process to develop effective educational interventions. Both the patient problem solving process and the instructional design process consist of seven nearly identical steps which follow a basic scientific problem-solving approach. Knowledge of this similarity can improve the effectiveness of educational activities developed by physicians.

Prospective evaluation of complications in an endoscopy unit: use of the A/S/G/E quality care guidelines

In 1989, the American Society for Gastrointestinal Endoscopy released a quality assurance monograph in which a procedure review process was outlined. The major elements of the program for quality assurance in gastrointestinal endoscopy included: (1) procedure reports, (2) an endoscopic unit record, and (3) a procedure review. This study was designed to use the procedure review process to determine the incidence of complications, to identify quality assurance issues, and to determine whether audits and/or studies would result from this process. To make a meaningful interpretation as to what constitutes an important complication, a classification to define potential problems was established. Using this classification, a complication was identified in 64 of 3287 procedures (1.9%). These complications were discussed in a monthly morbidity and mortality conference. Additionally, 21 quality assurance issues were identified that led to four studies addressing these quality assurance issues.

The knowledge and beliefs of family care givers about chronic pain patients

The knowledge and beliefs of 34 care givers (CGs) of chronic pain clinic patients were assessed regarding the causes of the patients' disorders, the CGs' preferred treatment and their contribution to it. Most CGs expressed dissatisfaction with previous investigations. They believed that there might be an undiscovered physical cause and favoured physical treatments, despite unsuccessful multiple past physical investigations and management. They claimed that they had been offered little information by medical staff or other health professionals concerning causes and treatment and nothing regarding how they could help. However, a few CGs had positive views concerning psychological contributions to aetiology, the potential value of increased activity and their own contribution to this, but these had not been exploited. Almost all CGs had previously been closely involved in the provision of care for invalids. Care givers were more likely to pursue physical explanations and treatments if pain duration was less than two years and preferred rest for female and older patients. We conclude that CGs lack essential information concerning the causes of chronic pain, its appropriate treatment and their own potential contribution. This may be an important impediment to successful rehabilitation.

Manometric characterization of rectal dysfunction following radical hysterectomy

Bladder dysfunction thought to be due to partial denervation has been described following radical hysterectomy. Some patients experience acute and chronic rectal dysfunction characterized by difficulty with defecation and loss of defecatory urge. To define this abnormality, anorectal pressure profiles were examined in 15 patients with Stage I carcinoma of the cervix before and after radical hysterectomy. Profiles were done using standard anorectal manometry with a water-infused system. In all patients preoperative manometric profiles were normal; postoperative studies were abnormal in all patients. Features seen include altered relaxation of the internal sphincter, increased distension needed to trigger relaxation, and decreased rectal sensation; external sphincters and resting internal sphincters were unchanged. Postoperatively, 12 patients reported problems with rectal function. A physiologic defect is definable in patients undergoing radical hysterectomy; this suggests disruption of the spinal reflex arcs controlling rectal emptying. These physiologic abnormalities correlate with the clinical symptomatology experienced by some patients. Continuing definition and evaluation of management options in this situation should be useful in developing effective therapy for rectal dysfunction following radical hysterectomy.

Control of lower esophageal sphincter pressure by two sites in dorsal motor nucleus of the vagus

Our purpose was to determine the central vagal sites for regulating changes in lower esophageal sphincter (LES) pressure in the cat. Injection of the retrograde tracer, horseradish peroxidase, into the LES resulted in labeling of cells in the dorsal motor nucleus of the vagus (DMV), with the largest number of cells appearing in two areas, one area rostral to obex (1.5-4.0 mm) and one area caudal to obex (-0.5 to -1.5 mm). In alpha-chloralose-anesthetized cats, L-glutamic acid was microinjected into these areas and LES pressure, intragastric pressure, and stomach motility were monitored. Microinjection of L-glutamic acid into the rostral area resulted in significant increases in LES pressure (18.6 +/- 4.9 mmHg; P less than 0.05), pyloric motility (baseline minute motility increased from 5.7 +/- 2.2 to 14.5 +/- 3.9 postinjection; P less than 0.05) and stomach pressure (baseline of 16.9 +/- 2.3 mmHg increased to 23.8 +/- 3.7 mmHg postinjection; P less than 0.05). Microinjection of L-glutamic acid into the caudal area resulted in significant decreases in LES pressure (-14.3 +/- 5.8 mmHg; P less than 0.05) and intragastric pressure (-7.5 +/- 2.2 mmHg; P less than 0.05) with no significant changes in pyloric motility. Ipsilateral vagotomy abolished both sets of responses. These data indicate that excitatory and inhibitory control of LES and intragastric pressure are mediated by vagal efferent neurons located in two distinct sites in the DMV.

Teicoplanin compared to flucloxacillin for antibiotic treatment of neutropenic patients

Ninety-eight neutropenic patients were randomized to receive piperacillin and gentamicin in combination with either teicoplanin or flucloxacillin. Sixty-seven of these patients, most of whom had myeloma, were given this combination as prophylaxis 5 d after high dose chemotherapy, 35 receiving flucloxacillin and 32 receiving teicoplanin. Of 31 patients with leukaemia who were febrile and neutropenic following induction chemotherapy or bone marrow transplantation, 18 received flucloxacillin and 13 received teicoplanin. For those given flucloxacillin, the mean number of days to change of antibiotics was 7.8 in the prophylaxis group and 5.1 in the treatment group. In the teicoplanin arm, the mean number of days to change antibiotics was 6.8 in the prophylaxis group and 6.1 in the treatment group. Two patients in the flucloxacillin arm developed drug rashes. Four patients developed rigors after teicoplanin administration and one asthmatic became wheezy. One patient had a progressive rise in creatinine, but overall the patients having teicoplanin did not have any appreciable increase of renal toxicity compared to the flucloxacillin arm. Blood cultures were positive prior to commencement in the treatment group in nine patients, and during treatment in six patients. Organisms grown were Gram-positive in 14 patients. Teicoplanin appears to be as effective as flucloxacillin when each is used in combination with piperacillin and gentamicin in the treatment of neutropenic patients, with similar rates of toxicity.

Who should perform the AIMS examination?

Psychiatrists and nonphysician mental health professionals working in community mental health centers have difficulty establishing the scope of their expertise, defining the limits of their roles, delegating responsibility, and sharing professional liability. The clinical, political, and administrative aspects of these tensions are examined in the context of arguments for and against physicians' delegating to nonphysician mental health professionals the task of screening CMHC patients for tardive dyskinesia using the Abnormal Involuntary Movement Scale. In 43 percent of mental health centers in Massachusetts surveyed by the authors, nonphysicians perform tardive dyskinesia screening. The authors suggest that the benefits of involving nonphysicians in tardive dyskinesia screening in the CMHC setting outweight the disadvantages.

Pregnancy-associated thrombocytopenia: definition, incidence and natural history

We have sought to clarify the definition and importance of newly diagnosed thrombocytopenia in pregnant women by establishing an appropriate reference interval for the platelet count, and by observing the outcome in a cohort of thrombocytopenic pregnant women. The mean platelet count was lower in 2,155 healthy pregnant than non-pregnant women, and varied with race, but did not fall with increasing gestation, except in Black women. 101 of approximately 2,800 women became newly thrombocytopenic during pregnancy by conventional criteria (platelets less than 150 x 10(9)/l), without an apparent cause. Using the reference intervals established during the study, however, 24 of these women would not have been regarded as thrombocytopenic. No bleeding tendency was observed in the mothers or their infants. Maternal platelet counts became normal in the postnatal period. Thrombocytopenia occurring for the first time during pregnancy may be a different condition from auto-immune thrombocytopenia, and we suggest the term 'pregnancy-associated thrombocytopenia' (PAT). PAT does not appear to be epidemic; it does not threaten the fetus, but it cannot be distinguished from auto-immune thrombocytopenia in individual cases.

TRH: immunocytochemical distribution in vagal nuclei of the cat and physiological effects of microinjection

In the present study, we have applied antiserum to thyrotropin-releasing hormone (TRH) and avidin-biotin immunocytochemistry to determine the distribution of TRH-like immunoreactivity in the vagal nuclei of the cat. A dense network of TRH-immunoreactive (TRH-IR) fibers and terminals is noted in the dorsal motor nucleus of the vagus (DMV) from 0 to 2.5 mm rostral to the obex. Horseradish peroxidase conjugated wheat germ agglutinin (HRP-WGA)-labeled neurons are noted in this region of the DMV after application of the tracer to the musculature of the pylorus. In dual-stained sections, TRH-IR fibers and terminals appear to terminate in close proximity to HRP-WGA-labeled neurons in the DMV. In contrast, a moderate to low density of TRH-IR fibers and terminals is noted in the nucleus ambiguus (NA), and no HRP-WGA-labeled neurons are noted in this nucleus. To determine the physiological significance of TRH fibers in these vagal nuclei, TRH was microinjected into the DMV and NA while monitoring gastric (antrum and pylorus) and duodenal motility as well as mean blood pressure (MBP) and heart rate. Microinjections of TRH (16-500 ng) into the DMV resulted in increases in pyloric and antral motility (minute motility index increased from 1.28 to 8.70 in the pylorus, P less than 0.05, and from 2.29 to 4.25 in the antrum, P less than 0.05). TRH microinjection also increased the intraluminar pressure in the stomach by 6.1 +/- 1.3 mmHg. No significant changes in duodenal motility, MBP, or heart rate were noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of a laser balloon for the treatment of gastrointestinal obstruction

This work describes the initial results using a laser balloon in a canine model in an attempt to deliver the energy in a circumferential pattern. A balloon catheter, 2 cm long and 3 mm in diameter, was developed. Using a standard cw 100 watt Nd:YAG laser, a 600 micron fiber was tapered to 200 microns and passed through the proximal end of the balloon. Laparotomies were performed on mongrel dogs 14-18 kg in weight. After a gastrotomy, the gastric mucosa was exposed and rugal folds were pulled over the balloon to create a cylinder. Using power settings between 10 and 60 watts, and pulse durations between 10 and 40 seconds, radial energy was delivered and the tissue was examined for both gross and histologic effects. Circumferential zones of coagulation and necrosis were demonstrated.

Transcultural patterns of somatization in primary care: a preliminary report

The ethnic origins of patients consulting their general practitioners (GP) were determined using criteria of country of birth, religion and preferred language. Three samples with preferred languages of English, Gujarati or Urdu were compared on a standardized interview with regard to symptom complaint, perception and attribution and also completed the General Health Questionnaire and Illness Behaviour Questionnaire. Their GPs provided diagnoses and ratings of physical and mental disorders. Compared with the English group, the Gujaratis had fewer psychosocial complaints, perceived less anxiety and were more likely to attribute their complaints to physical causes. They had higher scores on the Hypochondriasis and Denial scales. Their GPs rated them as less likely to have relevant physical or mental disorders. The Urdu group was intermediate in most respects. Thus somatization was commoner in these two Asian groups with different ethnic origins. However, overall levels of somatization appear to be high even in the English group. No significant differences were found between groups for complaints or ratings of depression, and the differences found in the somatization process appear to be related only to anxiety.

Psychological treatment of chronic pain: a selective review

Chronic pain occurs commonly in patients who have either physical or mental disorders, or both. Almost any psychiatric diagnosis may be involved, but affective and somatoform disorders predominate, together with adjustment disorders and psychological factors affecting physical condition. Psychological treatments for chronic pain have developed rapidly within the last 15 years. Most treatment is provided in the form of multi-faceted 'packages' incorporating a range of methods which are derived from operant or cognitive-behavioural theories. A selective review of these approaches leads to the conclusion that in general there is good evidence for their efficacy, despite the limitations of many research reports. There is still considerable uncertainty about the most effective treatments for different patients with different disorders. The effects on treatment outcome of litigation and compensation and of family factors are briefly considered. Despite the considerable cost resulting from chronic pain there appears to be meagre treatment available in the United Kingdom, particularly for the most severely disabled.

Effect of hypothyroidism on the expression of three microtubule-associated proteins (1A, 1B and 2) in developing rat cerebellum

The microtubule-associated proteins 1A, 1B and 2 are present at high levels in Purkinje cell dendrites of normal adult rat cerebellum but show characteristic changes in localization during cerebellar development that allow examination of the effects of hypothyroidism on the development of both Purkinje cells and granule cells. Neonatal rats were made hypothyroid by treatment with propylthiouracil from the day of birth (post-natal day 0, P0). The expression of the microtubule-associated proteins 1A, 1B and 2 in the cerebellum of hypothyroid animals was examined using immunocytochemical techniques and compared to the normal developmental pattern in control animals. The normal developmental decrease in microtubule-associated protein 1A and 1B levels in parallel fibres was delayed in the cerebellum of hypothyroid animals and these proteins persisted in parallel fibres until after P20. Microtubule-associated protein 1B but not 1A was still present in parallel fibres in less mature folia at P30 in hypothyroid rats suggesting that the expression of these two microtubule-associated proteins is regulated separately. In the molecular layer staining with anti-microtubule-associated protein 2 was enriched in Purkinje cell dendrites in normal and hypothyroid cerebella and the stained Purkinje cell dendrites in hypothyroid cerebellum demonstrated a typical deformed morphology at P15. The results show that the restricted subcellular localization of these microtubule-associated proteins is maintained in the cerebellum of hypothyroid rats but the developmental changes in their expression are delayed.

How to examine patients using the Abnormal Involuntary Movement Scale

The Abnormal Involuntary Movement Scale (AIMS) examination has been widely recommended for periodic screening for tardive dyskinesia and follow-up of patients diagnosed with the disorder. However, few guidelines exist about how to use the examination in clinical practice. The authors discuss for whom, when, and how the AIMS examination can be used in a multidisciplinary setting; amplify the original instructions for the examination; and propose conventions to clarify scoring. Noting that the AIMS examination is not specific for tardive dyskinesia, they discuss a clinical approach to the patient who is found to have abnormal movements. The AIMS examination is best conducted within the context of an ongoing treatment program, the authors say, and should be part of the informed consent process necessary with patients treated with neuroleptic drugs.

The ultrasonographic appearances of hilar cholangiocarcinoma (Klatskin tumours)

The findings on ultrasound of 40 patients presenting between 1984 and 1987 who were subsequently proven pathologically to have hilar cholangiocarcinoma were reviewed. The sonograms of 17 other patients in whom pathological confirmation was not obtained but who were also presumed to have Klatskin tumours on clinical and radiological grounds, were also reviewed. All patients demonstrated intrahepatic bile duct dilatation with no evidence of free communication between the right and left hepatic ducts. A hilar mass was observed in 74% of the patients. Seventy-nine per cent of the hilar masses were of increased echogenicity relative to surrounding liver, 19% were of reduced echogenicity and 2% of mixed echogenicity. An intraluminal mass was seen in 21% of the patients and bile duct wall thickening was observed in 4%. The mass detection rate of different ultrasound equipment was also compared. In 15 patients the ability of ultrasound to predict the order of intrahepatic bile duct involvement was compared with cholangiography.

Acute esophageal stricture after bone marrow transplantation

Gastrointestinal complications following bone marrow transplantation are common and may result from the conditioning regimen, immunosuppression, graft-versus-host disease, or a combination of these factors. These effects may be acute (mucositis, enteritis, esophagitis) or delayed (xerostomia, stricture formation) in onset. We describe here a case of esophageal stricture developing within 1 month of allogeneic bone marrow transplantation.

Anorectal contractility under basal conditions and during rectal infusion of saline in ulcerative colitis

Pressure activity in the rectum and anal canal was measured with a multilumen probe in 29 patients with ulcerative colitis (12 active, 11 quiescent, six studied during both phases) and 18 normal controls under resting conditions and during rectal infusion of saline. Resting motor activity was significantly decreased in patients with active colitis compared with quiescent colitis (p less than 0.005) and normal controls (p less than 0.001). Forty per cent of active colitics showed a featureless record compared with only one patient with quiescent colitis and one normal subject. The volume of saline infused before leakage occurred, and the total volume retained were significantly lower (p less than 0.001) in patients with active and quiescent colitis compared with normal controls. Rectal infusion of saline provoked regular rectal contractions, of significantly higher (p less than 0.05) amplitude in patients with active colitis, than in quiescent colitis or controls. These rectal contractions were associated with simultaneous anal relaxations. During saline infusion, peak and pressures were lower in patients with ulcerative colitis than in normal subjects, but there were no significant differences in relaxation pressures. In normal subjects, the rectal pressures remained below the anal pressures throughout the saline infusion. Peak rectal pressures exceeded the anal relaxation pressures during the last five minutes of saline infusion in patients with ulcerative colitis and throughout the infusion in those patients who complained of incontinence. Results suggest that although the resting rectal motor activity is diminished in patients with ulcerative colitis, luminal distension causes the inflamed rectum to generate abnormally strong contractions that may threaten continence.