Making sense of 'possession states': psychopathology and differential diagnosis

Possession is a common manifestation of distress in a multicultural setting. It is increasingly likely to be encountered by mental health professionals who may be unaware of the phenomenon. A review of the literature is presented with clinical guidelines for a culturally sensitive assessment and management.

A pre-operative mydriatic regime using a single application of tropicamide Novel Ophthalmic Delivery System and guttae phenylephrine 10%

Tropicamide Novel Ophthalmic Delivery System (NODS) and guttae (g.) phenylephrine 10% was applied once, 2 hours before cataract surgery, as an alternative to our standard pre-operative regime of g. cyclopentolate 1% and g. phenylephrine 10% used four times before surgery. The two treatment groups were compared using a randomised, prospective, observer-masked study design. The horizontal pupil diameter was significantly smaller using the new regime but the per-operative decrease in diameter was not significantly different, suggesting that surgical miosis was not influenced by reducing the number of mydriatic applications. There was no difference in the subjective grading of the pupil, suggesting that adequate mydriasis suitable for cataract surgery was obtained using the alternative regime. No major complications were documented in relation to the use of NODS. We discuss why less intensive mydriasis is likely to be as efficacious and describe its potential advantages.

Assessment of Yqh translocations

Two initially presumed Yqh translocations, one to Xp and another to 21p, were assessed by conventional banding procedures, 5-azacytidine treatment, electron microscopy, and fluorescence in situ hybridisation. While the Yqh nature of the heterochromatic block from Xp was confirmed, this was not the case with the 21ph+ variant. In conclusion, conventional banding techniques are insufficient to diagnose Y;G translocations.

An extra band within the human 9qh+ region that behaves like the surrounding constitutive heterochromatin

An extra variant G band in a human 9qh+ region was analysed in normally condensed and 5-azacytidine undercondensed chromosomes. Fluorescence in situ hybridisation showed that specific, classical, alphoid and beta satellite DNA was not present. Nevertheless, this extra band behaves like the surrounding heterochromatin because (1) its chromatin fibres showed condensation inhibition after 5-azacytidine treatment, as confirmed by electron microscopy, and (2) it was not affected by in situ digestion with the restriction endonucleases AluI and Sau3A. These results suggest that this variant band may correspond to euchromatin that has become inactivated by a position effect.

[The risk of diabetes mellitus in relatives of diabetics treated with insulin]

The objective of this study was to compare the risk of diabetes mellitus in the relatives of type 1 (defined as cases diagnosed before 40 years and beginning insulin less than two years later) and in those of type 2 diabetics, treated with insulin. A random sample of 303 patients was obtained from responders to a postal survey sent to all 2800 diabetics living in the Oporto self county and identified as users of insulin the injection pen. After selecting those who completed the questions for sex, age, dates of diabetes diagnosis and of first insulin prescription, we were left with 192 index cases. They provided data concerning sex; age, and presence of diabetes for 1370 relatives (parents, siblings, offspring and spouses). The risk of diabetes (unspecified type) in family members was significantly lower in relatives of type 1 diabetics (OR = 0.31, CI 95%:0.19-0.48, p < 0.0005). This family risk was lower when the index case was a male (OR = 0.24, CI 95%:0.12-0.47 vs OR = 0.39, CI 95%:0.21-0.74) or for female relatives (OR = 0.22, CI 95%:0.11-0.42 vs OR = 0.43, CI 95%:0.22.-0.82). After adjustment for confounders applying logistic regression to each family stratum, the risk remained significantly lower for parents (OR = 0.35, CI 95%:0.17-0.71) and siblings of type 1 diabetics compared to similar relatives of type 2 cases (OR = 0.84, CI 95%:0.06-10.6) but was not significantly different for the offspring (OR = 0.68, CI 95%:0.11-4.17) or the spouses (OR = 0.84, CI 95%:0.06-10.6).(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency of sister chromatid exchanges in humans at 14-16 week foetal stage and at birth

In order to identify transplacental induced mutagenicity in humans the baseline frequency of sister chromatid exchanges (SCEs) in amniotic fluid cells (8.56 +/- 0.28 per cell) from 14 to 16-week-old foetuses as well as in peripheral blood lymphocytes (7.96 +/- 0.26 per cell) from newborns was determined. A group of twelve patients who were analysed both at 14-16 weeks gestation and at birth showed no SCE variations. These results suggest that foetal amniocytes and T lymphocytes from newborns present a similar sensitivity to the mutagenic activity of the thymidine analogue 5-bromodeoxyuridine employed in the sister chromatid differentiation.

Endoscopy: throat spray or sedation?

Anxious patients tolerate endoscopy poorly. It was proposed that such patients might derive most benefit from sedation, while most non-anxious patients would prefer endoscopy with lignocaine throat spray alone. In a prospective study, 200 outpatients underwent diagnostic endoscopy after receiving one of two detailed information sheets which offered them either the choice between spray or sedation (n = 100) or the same choice but encouraged those who were anxious about endoscopy to choose sedation (n = 100). When given an informed choice, most non-anxious patients prefer not to be sedated most non-anxious patients prefer not to be sedated during diagnostic endoscopy. If patients who are anxious about the procedure are advised to choose sedation, those who nevertheless opt for topical throat spray alone find the endoscopy just as comfortable. If the endoscopy were to be repeated, 73% of the spray group and 77% of the sedation group would make the same choice again. Of 33 patients who chose spray but had been given only sedation for a previous endoscopy, 26 (79%) would choose spray again for a future endoscopy. The choice of spray or sedation should reflect the patient's view as well as that of the endoscopist.

5-azacytidine produces differential undercondensation of alpha, beta and classical human satellite DNAs

Fluorescence in situ hybridization employing human alphoid, beta and classical satellite DNA probes was performed on 5-azacytidine treated and untreated chromosomes obtained from human lymphocytes. The individual used in this study presented a polymorphism of constitutive heterochromatin of chromosomes 1 and 9 as revealed by in situ digestion with the restriction endonuclease Alul. Neither the alphoid nor the beta satellite DNA domains were susceptible to condensation-inhibition by 5-azacytidine. Only the classical satellite localized on chromosome 9 was affected. The constitutive heterochromatin size polymorphism was shown to depend mainly on variations of the classical satellite DNA domain. Therefore, condensation-inhibition, as a phenomenon which may modify the natural folding of the chromatin fibre, regionally affects human constitutive heterochromatin and seems to be dependent on the heterochromatic family.

Detection of a Cytosolic Glutamine Synthetase in Leaves of Nicotiana tabacum L. by Immunocytochemical Methods

Two glutamine synthetase (GS) polypeptides (44 and 39 kD) were immunodetected on western blots of leaf extracts from tobacco (Nicotiana tabacum L.), a plant that has been reported to contain only chloroplast GS in the leaves. By immunocytochemical methods, we confirmed the localization of GS in the cytosol of cells in the vascular tissue and in the chloroplasts of mesophyll cells.

[Echocardiography-guided temporary implantation of electrode catheters: an alternative with reliable results even during prolonged use]

OBJECTIVE

Two-dimensional echocardiography (2D-ECO) evaluation as an alternative guidance technique during temporary pacing wire placement.

DESIGN

Prospective evaluation of implantation and pacing parameters.

SETTING

Admission from the Emergency Room and patients studied in the Cardiology Department of the Hospital Distrital in Faro.

PATIENTS

Twenty patients with indication for temporary cardiac pacing during, at least, twelve hours (H). Fluoroscopy equipment shouldn't be readily available for implantation.

INTERVENTIONS

The mean ages of the 20 pts. (14 men and 6 women) were 71.90 +/- 2.12 years. All pts. had a temporary pacing lead implantation under 2D-ECO guidance. Indications for cardiac pacing were: second or complete atrioventricular block (17 pts.), new onset bifascicular bundle branch block during anterior acute myocardial infarction (1 patient) and sick sinus syndrome (2 pts.). The transvenous route of approach has been the right internal jugular in all the cases and venipuncture time accounts for the calculation of total implantation time.

MEASUREMENTS AND RESULTS

Ventricular capture was achieved in all pts., with stable stimulation thresholds. The mean implantation time was +/- 9.21 minutes and the mean acute stimulation threshold 0.33 +/- 0.20 V and 0.65 +/- 0.35 mA. The mean voltage of the intracavitary QRS was 11.15 +/- 2.95 mV and the mean lead resistance was 851.33 +/- 194.04 Ohms. The mean utilization time of the pacing leads was 95.15 +/- 87.49 H and the mean stimulation threshold during lead explanation was 0.85 +/- 0.47 mA. The only complication appearing during our study has been one lead dislodgment (5%), 72 h after implantation, placed again with the guidance of 2D-ECO and used during 216 H without further complications. Subcostal 2D-ECO window alone was used in 85% of the pts. but in the remaining (15%), it was insufficient and an apical window was needed too.

CONCLUSIONS

The 2D-ECO was an efficient alternative technique of guidance during temporary lead placement, ensuring satisfactory longterm pacing and sensing. Our results indicate that 2D-ECO may be the best alternative control for urgent lead implantation whenever fluoroscopic facilities are remote or logistically not convenient.

Ascites adenosine deaminase activity is decreased in tuberculous ascites with low protein content

The value of adenosine deaminase activity (ADA) in ascitic fluid was examined in 12 patients with confirmed peritoneal tuberculosis and compared with that of 96 patients with ascites of other different etiologies as an age-matched control group, to determine the diagnostic value of the ADA activity in tuberculous ascites. The mean adenosine deaminase activity (ADA) value in ascitic fluid of the tuberculous peritonitis group was 47.9 +/- 21.9 IU/L and in the control group 9.6 +/- 5 U/L (mean +/- SD); p less than 0.01. A different method than that usually reported in tuberculous peritonitis was used for ascites ADA estimation. The best sensitivity and specificity was obtained when greater than 32 U/L was used as a cutoff point. The ascites ADA activity correlated with the ascites total protein concentration in the tuberculosis group (r = 0.842). Our findings confirm other results and support the ADA activity determination in ascitic fluid as a useful noninvasive screening test in the diagnosis of peritoneal tuberculosis in endemic areas or in high risk patients. However, false-negative results may occur in those patients in which ascites total protein concentration is low.

The relationship of microbial pathogens to acute infectious diarrhoea of childhood

Bacterial, viral and parasitic enteric pathogens were detected in 692 of 916 children below 36 months of age with acute diarrhoea and in 289 of 587 matched controls. The rates of identification of only four groups of pathogens, rotavirus, Shigellae, Salmonella typhimurium and enterotoxigenic E. coli, were significantly higher in the patients. The prevalence of a variety of other enteric pathogens was similar in controls of patients. Shigellosis had a characteristic clinical profile but none of the other agents could be suspected on clinical grounds. The high prevalence of pathogens in controls suggested that the population may be partially protected against a variety of enteric pathogens and that final common pathways leading to diarrhoea may be activated by changes in the microbial ecology of the gut lumen.

[Morphologic course of the left ventricle after renal transplantation. Echocardiographic study]

OBJECTIVE

To characterize and to quantitate the morphologic changes in left ventricle, in renal transplant patients (Pts) treated with cyclosporine, through sequential echocardiographic examinations.

DESIGN

A prospective study of renal transplant patients, between October/88 and May/89, who maintained good function of the renal graft during the follow-up.

SETTING

Cardiology and Nephrology departments of Santo António Hospital.

MATERIAL AND METHODS

20 patients, 13 men and 7 women, mean age of 33 +/- 10, ranging from 20 to 56, constitute the final group of the study. These patients have been receiving dialysis during 3.8 +/- 2.3 years (0.4-8). Seven patients were excluded, five by echocardiographic criteria and another two because of chronic renal graft disfunction (creatinine greater than 2.0 mg%). The echocardiographic examinations were performed during the first week, and 1, 2, 3, 6 and 12 months after renal transplantation. The following measurements were performed: left ventricular end-diastole diameter (LVED), interventricular septal thickness (IVST), posterior wall thickness (PWT) and left ventricular mass index (LVMI). The measurements were obtained in M-mode following the conventional recommendations. Average values of at least 3 cardiac cycles were used. Heart rate, blood pressure, creatinine, hematocrit, body surface area and fistula patency, were determined at the time of each echocardiogram.

MAIN RESULTS

The LVED decreased progressively until the third month, from 51.9 +/- 7 mm to 47.8 +/- 6 mm (p less than 0.001), remaining stable thereafter. The baseline value of IVST, 13.6 +/- 5 mm, was similar at the twelfth month, 13.8 +/- 2 mm (ns). The baseline value of PWT, 13.7 +/- 4 mm, decreased gradually since the second month, having reached 12.7 +/- 2 mm at the twelfth month (ns). The LVMI (g/m2) reduced progressively, from 243 +/- 82 to 190 +/- 38 at the end of the study (p less than 0.05. A high incidence of arterial hypertension was detected during the follow-up period; at the twelfth month, 18 patients (90%) were on antihypertensive drug therapy, 11 of which had blood pressure greater than or equal to 160/95 mmHg.

CONCLUSIONS

We verified, one year after the renal transplantation, a significant decrease of LVMI, that was mainly determined by the LVED reduction. Left ventricular walls thickness had no significant variation; we think that the high incidence of hypertension during the follow-up period, in part due to the pressure effect of cyclosporine, may have been responsible for this fact.

New Secale cereale (rye) DNA derivatives for the detection of rye chromosome segments in wheat

Subcloning of a clone of the 120-bp family of rye, pSc119, has produced two extremely useful probes. pSc119.1 assays rye-specific dispersed repetitive sequence families. It is present on all seven rye chromosomes and hybridizes to the entire length of each chromosome, with the exception of some telomeres and the nucleolar organiser region. pSc119.2, in contrast, hybridizes predominantly to the telomeric regions of rye chromosomes, with some interstitial sites. Unlike pSc119.1, it assays similar repetitive sequence families in both wheat and rye chromosomes.

Haemolytic uraemic syndrome with prolonged anuria and cortical calcification: a case report

An 18-month-old infant presented with haemolytic uraemic syndrome following a prodrome of colitis. Incomplete recovery of renal function occurred after 4 weeks of anuria and was associated with extensive renal cortical calcification. During the recovery phase he had two relapses of colitis, microangiopathic haemolytic anaemia and thrombocytopenia without any deterioration in renal function.

Effect of bezafibrate on the sequelae of acute experimental focal cerebral ischaemia

The possibility that the ability of bezafibrate to lower the oxygen affinity of haemoglobin might lead to an increased oxygen delivery to ischaemic cerebral tissue was explored in preliminary studies in two animal models. The combined morbidity and mortality of unilateral carotid ligation in the gerbil appeared to be reduced at two hours in bezafibrate treated animals. By four hours and thereafter the outcome was unaffected. Two hours after MCA occlusion bezafibrate-treated rats showed a significantly reduced rise in tissue lactate concentration (p less than 0.01) suggesting less anaerobic metabolism had occurred in the ischaemic tissue.

Do leukocytes have a role in the cerebral no-reflow phenomenon?

The possible role of leukocytes in the cerebral microcirculation following ischaemia was assessed in the gerbil. The no-reflow phenomenon seen after 30 minutes of severe bilateral hemispheric ischaemia during hypotensive reperfusion was compared in control animals and in a group made leukopenic by pretreatment with cyclophosphamide. Neither the incidence nor the severity of the no-reflow phenomenon differed between the two groups. The evidence from this study casts doubt on the hypothesis that leukocyte plugging plays a major role in the cerebral microcirculation's response to ischaemia.

Cytoproteic CSF findings in 33 MS patients: usefulness for diagnosis

Although multiple sclerosis (MS) is mainly defined on clinical grounds, CSF parameters still remain important diagnostic and scoring tools. To demonstrate the usefulness of some easy laboratory techniques, a CSF cytomorphological and agarose gel electrophoresis (AGE) evaluation was undertaken in 33 MS patients: 79% presented a lymphoid cell profile and in 73% the gamma globulin fraction was abnormal. In the great majority of cases (97%) either or both cytological and electrophoretical abnormalities were found.

Autoantibodies and immunogenetics in 30 patients with systemic sclerosis and their families

Clinical and serological evidence of connective tissue disease was found in a high proportion of 132 family members of 30 patients with systemic sclerosis. In 20 probands with the milder CREST form of the disease, 10 had HLA-DR5 and 12 had null alleles at the C4 loci. None of 11 probands with more severe systemic sclerosis had HLA-DR5; all 11 had null alleles at the C4 loci. All but two of the probands had either HLA-DR5 or a C4 null allele, and this was also the case for the majority of the relatives with autoantibodies. Genetic markers of the major histocompatibility complex, including HLA-DR5 and C4 null alleles, appear to be closely associated with markers of disease in these probands and their families.

Genetic susceptibility to scleroderma-like syndrome in symptomatic and asymptomatic workers exposed to vinyl chloride

We have previously reported a genetic susceptibility to a scleroderma-like disorder in a group of workers exposed to polyvinyl chloride and this susceptibility could be mapped to the major histocompatibility complex area of the 6th chromosome. To date no genetic studies have been reported comparing affected with unaffected workers. We report such data and discuss it in the light of our previous findings in vinyl chloride exposed patients and in patients with classical scleroderma. Our results suggest that susceptibility to this disorder is increased in the presence of HLA-DR5 or of a gene in linkage disequilibrium with it and an antigen associated with the haplotype A1 B8, while DR3 favours progression of the disease.

Effects of deoxyadenosine on the activation of ADA inhibited T & B cells

Using an in vitro model of adenosine deaminase deficiency, we have shown that the triggering of T lymphocyte proliferation by PHA is inhibited by concentrations of deoxyadenosine likely to occur in the plasma of ADA deficient children with severe combined immunodeficiency (ADA-SCID). Prostaglandin E1 increases the sensitivity of T cells to this inhibition, suggesting that derangement of cyclic nucleotide metabolism underlies the profound T lymphopaenia seen in ADA-SCID and in patients treated with the ADA inhibitor, deoxycoformycin. The proliferation and Ig synthesis of ADA inhibited B cells stimulated with protein A and EBV is in general less sensitive to the inhibitory effects of deoxyadenosine. However, this sensitivity varies widely between experiments suggesting that other cells present in the cultures may modify the inhibitory effect of deoxyadenosine. This may help explain the variability in B cell numbers and function in patients with ADA-SCID.

Immature B cells in fetal development and immunodeficiency: studies of IgM, IgG, IgA and IgD production in vitro using Epstein-Barr virus activation

Epstein-Barr virus has been used as a B cell mitogen to explore the parallels between the B cells found in patients with hypogammaglobulinemia and the immature B cells in fetal tissues. Peripheral blood lymphocytes from 29 cases of late onset hypogammaglobulinemia (common variable immunodeficiency) and from 10 cases of X-linked hypogammaglobulinemia were depleted of T lymphocytes and stimulated with virus in vitro. Immunoglobulin production was measured over a 4-week culture period using inhibition radioimmunoassays for IgM, IgG, IgA and IgD. The results were compared with those seen with fetal liver cells, cord blood lymphocytes and adult lymphocytes. Virus-stimulated cells from fetal sources produced small amounts of IgG and IgA relative to IgM, the ratio of IgM to IgG in the second week being in all cases greater than 10. Similar patterns were seen in 25/29 cases of late onset hypogammaglobulinemia, and in the eight cases of X-linked hypogammaglobulinemia that responded in vitro. In contrast, the ratio of IgM to IgG was always less than 8 in cultures of normal adult peripheral blood or bone marrow lymphocytes, and also in cultures from four cases of hypogammaglobulinemia known independently to have abnormal circulating suppressor cells. Eight cases of selective IgA deficiency showed reduced IgA production; six of these showed a normal ratio of IgM to IgG production. Thus, the B lymphocytes which circulate in many patients with hypogammaglobulinemia are functionally immature.

Glanzmann's thrombasthenia. A review and report of 42 cases from South India

In the 14 year period from June, 1966 to June, 1980, 42 cases of Glanzmann's thrombasthenia have been diagnosed, all fulfilling the criteria of prolonged bleeding time, with normal venous platelet count, defective clot retraction and decreased platelet aggregation, associated with a lifelong bleeding tendency. Few cases have been reported from India though it is the fourth most common congenital bleeding disorder among the patients seen at the Christian Medical College Hospital, Vellore. The large number of such cases found in South India as compared with reports from other parts of the world may be due to the high degree of consanguinity which is part of the accepted culture in this area. Reliable diagnosis of this condition is possible with fairly simple laboratory procedures.

Essential athrombia. A report on 4 cases from South India

Four cases of essential athrombia have been diagnosed in the 14 year period from June, 1966 to June, 1980 at the Coagulation Laboratory of the Christian Medical College Hospital, Vellore. All cases fit Inceman's description of the original case and fulfill the diagnostic criteria of prolonged bleeding time, decreased platelet aggregation, normal platelet count, normal morphology and normal clot retraction. No cases have been reported from India in the past 15 years.

Axo-dendritic abnormalities in a case of juvenile neuronal storage disease

Axonal enlargements (meganeurites) and dendritic degeneration were found in the pyramidal neurons from the frontal cortex of a patient with juvenile neuronal storage disease studied with the aid of ultrastructural and Golgi methods. Meganeurites appeared as enlargements at the axon hillock-initial segment area and were similar to those described in other neuronal diseases; dendritic degeneration was heavy and appeared throughout the cell domain. These neuropile changes can be related to the precocious mental abnormalities observed in this group of diseases which depend on a storage phenomenon due to a lysosomal enzyme deficiency.

Two cases of rapidly progressive subacute sclerosing panencephalitis. Neuropathological findings

Two cases of rapidly progressive subacute sclerosing panencephalitis that brought about coma in less than three weeks and death in less than two months are reported. The ultrastructural observations of brain biopsy specimens from these patients found unusual neuropathological findings. These uncommon features are discussed on a cliniconeuropathological basis.

Oligoclonal gamma-globulin of cerebrospinal fluid in neurobrucellosis

The clinical manifestations and laboratory findings of two cases of neurobrucellosis are described. The cerebrospinal fluid (CSF) protein electrophoresis showed increased gamma-globulins and decreased relative values of pre-albumin and albumin, associated to high values of total CSF protein. The evidence of oligoclonal morphology of CSF gamma-globulins suggests that part of them had an intrathecal origin, in addition to an increased crossing of the damaged blood-CSF barrier. Similar oligoclonal appearance of CSF gamma-globulins was observed in two additional cases of neurobrucellosis previously reported.