A factor analysis of the signs and symptoms of mania

BACKGROUND

No adequate factor analyses of signs and symptoms of mania have been reported. From limited past reports, the view has arisen that 2 main symptom clusters (euphoric-grandiose and paranoid-destructive) occur in patients with mania, along with so-called core symptoms of psychomotor pressure. In this view, dysphoric mania is associated with paranoid-destructive symptoms and with psychosis.

METHODS

We rated 237 patients with DSM-III-R-defined bipolar disorder, manic (n = 204) or mixed (n = 33), on 15 classic features of mania and 5 features related to dysphoric mood. Principal components factor analysis was applied to the ratings.

RESULTS

Five clearly interpretable and clinically relevant factors were identified. The first and strongest factor represented dysphoria in mania, with strong positive loadings for depressed mood, lability, guilt, anxiety, and suicidal thoughts and behaviors and a strong negative loading for euphoric mood. Factors 2 through 5 represented psychomotor acceleration, psychosis, increased hedonic function, and irritable aggression, respectively. The distribution of weighted scores on factor 1 was bimodal, whereas the corresponding distributions of factors 2 through 5 were unimodal. Contrary to all past reports, no general factor denoting overall severity of mania was found. Factors previously proposed by Beigel and Murphy were not confirmed.

CONCLUSIONS

Five independent factors representing dysphoric mood, psychomotor pressure, psychosis, increased hedonic function, and irritable aggression were identified. The conventional view of symptom factors in mania was not confirmed. Dysphoric features are statistically salient in patients with mania, and the bimodal distribution of the dysphoria factor is consistent with the possibility that mixed bipolar disorder is a distinct state.

Final score in laparoscopic cholecystectomy. Cholangiogram 1207, no cholangiogram 116

BACKGROUND

The role of intraoperative fluorocholangiography (IOC) in laparoscopic cholecystectomy (LC) is controversial. We evaluated the use of IOC at an institution where the study is performed routinely.

METHODS

Records of all patients undergoing LC during a 3-year period ending January 1, 1996 were reviewed.

RESULTS

A total of 1207 patients received IOC, whereas 116 patients did not. IOC findings were categorized as follows: normal, 1016 cases (84%); CBD stone, 149 cases (12.3%); anomalies, 23 cases (1.9%); duodenal diverticula, 10 cases (0.8%); ductal strictures, four cases (0.3%); and CBD diverticula, 5 cases (0.4%). In the 116 patients who did not receive IOC, 35 of the procedures could not be performed, whereas 81 were not attempted. Of the 149 IOC that showed CBD stones, two were false positives. Anomalies included accessory right hepatic ducts (11 cases), cystic ducts joining the right hepatic duct (seven cases), and abnormal cystic duct entries (five cases). Duct injuries occurred in 5 cases (0.4%), three before and two after IOC. Four injuries were minor; IOC prevented CBD transection.

CONCLUSIONS

Routine IOC is feasible, safe, accurate, and provides critical information of immediate use during LC. By treating ductal stones at operation and identifying patients without CBD stones, IOC minimizes need for postoperative studies, including endoscopic retrograde cholangiography (ERC).

The performance of DSM-III-R major depression criteria in the diagnosis of bipolar mixed states

Two hundred thirty-seven (237) manic patients diagnosed by DSM-III-R criteria as either purely manic (204) or mixed bipolar (33) were reviewed for analysis of the diagnostic performance of the DSM-III-R criteria required to diagnose the mixed bipolar state. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic efficiency of each of the 9 DSM-III-R criteria for major depression in this cohort. As predicted, four of the major depression criteria had low diagnostic utility, with PPV's less than 0.3. Those items were: weight change; sleep disturbance; psychomotor change; and diminished ability to think or concentrate or indecisiveness. Four symptoms: anhedonia, fatigue, feelings of worthlessness or guilt, and recurrent thoughts of death or suicidal ideation had acceptable utility for the diagnosis of mixed states.

Discovery of CGS 27023A, a non-peptidic, potent, and orally active stromelysin inhibitor that blocks cartilage degradation in rabbits

Structure-activity relationships of a lead hydroxamic acid inhibitor of recombinant human stromelysin were systematically defined by taking advantage of a concise synthesis that allowed diverse functionality to be explored at each position in a template. An ex vivo rat model and an in vivo rabbit model of stromelysin-induced cartilage degradation were used to further optimize these analogs for oral activity and duration of action. The culmination of these modifications resulted in CGS 27023A, a potent, orally active stromelysin inhibitor that blocks the erosion of cartilage matrix.

Lack of relapse with tryptophan depletion following successful treatment with ECT

OBJECTIVE

Although the antidepressant mechanism of ECT is unknown, there are considerable data to support serotonergic involvement. The effects of tryptophan depletion were studied in patients with major depression treated successfully with ECT.

METHOD

Five patients who had been successfully treated with ECT for major depression were studied in a randomized, double-blind, crossover design comparing tryptophan depletion to a placebo procedure.

RESULTS

No effect of tryptophan depletion on mood symptoms was observed despite more than an 85% decrease in total serum tryptophan.

CONCLUSIONS

These data suggest that presynaptic serotonin availability may not be necessary for the acute maintenance of an antidepressant response to ECT.

Serotonin transporter expression in rat brain regions and blood platelets: aging and glucocorticoid effects

Hyperactivity of the hypothalamus-pituitary-adrenal axis is more common in elderly depression than in younger cohorts and glucocorticoids are known to influence serotonergic systems. The current study explores the interaction of glucocorticoids with aging on serotonin transporter expression and function. Continuous infusions of dexamethasone (26 days) reduced transporter expression in the aged brain but the ability of imipramine to inhibit synaptosomal [3H]serotonin uptake was unimpaired. These effects were unique to aged animals, as prior work with young adults found no effects of dexamethasone on transporter expression. In contrast to the effects in the brain, there were no differences in platelet transporter expression between young and old rats nor did dexamethasone treatment affect the values in the aged group: thus, the platelet may not reliably model these aspects of CNS function. The results suggest that there are basic biologic differences in the effects of glucocorticoids in aged vs. young brain that could contribute to lowered effectiveness to antidepressants in elderly depression; if transport capacity is already reduced by the effects of increased glucocorticoids, further inhibition of transport by antidepressants would have proportionally less impact on synaptic serotonin concentrations.

Routine cholangiography reduces sequelae of common bile duct injuries

BACKGROUND

An effort was made to determine whether a policy of routine cholangiography affects the incidence, morbidity, and cost of bile duct injuries.

METHODS

A retrospective review of consecutive 3,242 laparoscopic cholecystectomies was performed. Most patients had routine intraoperative cholangiography.

RESULTS

There were 12 bile duct injuries (0.37%). All injuries were Bismuth levels 1 and 2. Eleven of 12 injuries were recognized intraoperatively. Ten were repaired primarily and one required hepaticojejunostomy. All repairs were successful. Average hospital charges were $26,669. One of 12 patients had delayed recognition of a bile duct injury and underwent primary repair over a T-tube on postoperative day 7. Hospital charges were $43,957.

CONCLUSION

Routine cholangiography did not appear to decrease the absolute incidence of bile duct injuries compared to previously published reports. Injury severity, morbidity, late sequelae, and costs were reduced by a policy of routine cholangiography.

Update on transcystic exploration of the bile duct

Selective use of transcystic bile duct exploration during laparoscopic cholecystectomy is a safe and highly effective approach for treatment of most common duct stones. The technique obviates the need for selective endoscopic retrograde cholangiopancreatography-sphincterotomy prior to cholecystectomy and is a more cost-effective approach.

Laparoscopic splenectomy for ITP. The gold standard

BACKGROUND

A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed.

METHODS

The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed.

RESULTS

Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 +/- 35 min) significantly shorter than for the first ten (p = 0.01) and also shorter than for OS (103 +/- 45 min). Postsurgical hospital stay was 2.9 +/- 1.3 days for LS and 6.9 +/- 3. 0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 +/- 0. 5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 +/- 3,636 for LS and $9,031 +/- 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group.

CONCLUSIONS

LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS.

Recognition of laparoscopic bile duct injuries by intraoperative ultrasonography

BACKGROUND

The purpose of this study was to investigate the possibility of detecting bile duct injuries using laparoscopic intraoperative ultrasound (LIOU).

METHODS

Fifty bile duct injuries were created using laparoscopic techniques in ten farmer pigs. The lesions created were: (1) partial occlusion, (2) complete occlusion (1 clip), (3) complete occlusion (2 clips), (4) transection between clips, (5) excision between clips.

RESULTS

All injuries were easily visualized using LIOU. The relation of clips impinging upon or occluding the bile duct was readily visualized on LIOU in all cases. In some cases it was difficult to distinguish between partial and complete occlusion. It was also difficult to distinguish between transection and excision due to retraction of the severed bile duct.

CONCLUSIONS

In cases of iatrogenic occlusion of the bile duct involving hemoclips (including transection or excision between clips), LIOU is a potentially useful modality that may allow earlier recognition and repair. Further studies are needed to evaluate the efficacy of LIOU in detection of bile duct injuries that do not involve hemoclips.

Serum prolactin, electrode placement, and the convulsive threshold during ECT

This study examines the relationship of serum prolactin changes (delta PRL) to variations in electrode placement after controlling for differences in the convulsive threshold. Previous studies showing greater release of PRL with bilateral (BL) compared with right unilateral (RUL) electrode placement were conducted without knowledge of the convulsive threshold. Twenty-two patients each received threshold RUL, threshold BL, 2.25 times threshold RUL, and 2.25 times threshold BL ECT. Serum PRL was collected 5 min before and 15 min after each electroconvulsive therapy (ECT). The convulsive threshold was greater for BL than RUL electrode placement. delta PRL was greater with BL than RUL ECT at comparable relative stimulus intensities. delta PRL was not correlated with seizure duration or absolute stimulus dose.

Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy

BACKGROUND

In the United States of America, approximately 700,000 patients undergo laparoscopic cholecystectomy (LC) each year and at least 10 percent of these patients will have common bile duct stones (CBDS). The purpose of this study was to evaluate patients with choledocholithiasis and compare the economic and clinical results obtained by LC with endoscopic sphincterotomy (ES) with those of LC with laparoscopic transcystic common bile duct exploration (LTCBDE).

STUDY DESIGN

From June 1991 to September 1994 patients undergoing LC plus LTCBDE and those undergoing LC plus ES at a single institution were compared where cost data were available. Of the 76 patients with choledocholithiasis, 59 patients underwent LC plus LTCBDE (group 1) and 17 patients underwent LC plus ES (group 2). A subset of group 1 patients undergoing urgent LC plus LTCBDE (group 3) for cholecystitis, cholangitis, or pancreatitis plus laparoscopy were examined separately.

RESULTS

Laparoscopic cholecystectomy plus LTCBDE, whether including all-comers (group 1) or just urgent cases (group 3), was associated with a significantly decreased length of hospital stay (6.1 and 6.9 days, respectively, compared with group 2, 12.4 days) (p < 0.001). The morbidity of patients in group 1 was also markedly lower than for patients in group 2; 12 percent compared with 41 percent, respectively. Patients in group 1 had a significantly decreased cost of hospitalization (+13,151), when compared with patients in group 2 (+18,712) (p = 0.05). This difference is even more pronounced when professional fee reimbursement is considered. The cost of treatment for patients in group 1 was +14,732 compared with +21,125 for patients in group 2 (p < 0.05). The total hospital cost for patients in group 3 was only +13,564 compared with +18,712 for patients in group 2. When professional reimbursement was considered, the cost was +15,150 for patients in group 3 compared with +21,125 for patients in group 2.

CONCLUSIONS

Patients undergoing LC plus LTCBDE for CBDS, whether urgently or electively, have markedly decreased morbidity rates, length of hospital stay, and costs when compared with patients undergoing LC plus ES.

One hundred consecutive laparoscopic cholangiograms. Results and conclusions

BACKGROUND

In 100 consecutive patients who underwent laparoscopic cholecystectomy, the feasibility, reliability, and cost of routine laparoscopic cholangiography were prospectively studied.

METHODS

Fluoroscopic cholangiograms with multiple exposures were successfully completed in all patients in an average time of 6.9 min.

RESULTS

Twenty-one percent were abnormal, and 15 common duct stones and 6 significant anatomic anomalies detected. Thirteen out of 15 patients with common duct stones had preoperative suspicion of common duct stones. Two out of 15 were completely unsuspected. The average cost of cholangiography was $768, and there were no complications related to the procedure. There were no false interpretations.

CONCLUSIONS

When compared with selective preoperative endoscopic retrograde cholangiopancreatography (ERCP), routine laparoscopic cholangiography is safer, more accurate, and less costly, and may have the added benefit of potentially reducing iatrogenic injuries in patients with anatomic variations. Routine laparoscopic cholangiography should be considered by all surgeons.

Short-term variability of mood ratings in unipolar and bipolar depressed patients

The ability of depressed patients to assess their mood states is controversial. We devised a scale consisting of a global item and 23 multiple visual analog items based on the Carroll/Klein model of depression. Short-term reliability of self-ratings in 13 unipolar and 11 bipolar depressed patients was tested. Subjects completed the scale and were retested 1 h later. Global clinician and self-ratings demonstrated similar episode severity between the groups and global self-ratings were highly reliable at retest for both groups. Unipolar depressed patients demonstrated high retest reliability on individual items of the MVAS. Bipolar patients demonstrated greater variability of responses suggesting greater short-term mood fluctuation in bipolar patients.

The Drop Volume Method for Interfacial Tension Determination: An Error Analysis

An error analysis of the drop volume method of determination of surface or interfacial tension is presented. It is shown that the presence of the empirical correction term may lead to either a decrease or an increase in the final uncertainty of the calculated tension. Recommendations to maximize the precision of measurement are made. It is further shown that the systematic error due to the correction term is less than 0.04%; under the conditions recommended to minimize the statistical uncertainty, the systematic error should be less than half this figure. Tabulations of recommended values of the correction function are given.

Laparoscopic colectomy vs traditional colectomy for diverticulitis. Outcome and costs

BACKGROUND

The aim of this study was to evaluate the outcome of patients undergoing laparoscopic colectomy for diverticulitis.

METHODS

Fourteen consecutive patients undergoing laparoscopic sigmoid colectomy (LSC) for diverticulitis were evaluated. Medical records from a control group of 14 matched patients undergoing traditional open sigmoid colectomy (OSC) for diverticulitis were reviewed for comparison.

RESULTS

Mean age, operative time, morbidity, and mortality of the LSC and OSC groups were not significantly different. However, the mean estimated blood loss (171cc vs 321cc), days to p.o. liquids (2.9 vs 6.1), and postoperative stay (6.3 vs 9.2 days) were all significantly less in the LSC patients. Although the mean operating room charges were greater in the LSC patients ($10,589 vs $8,207) the mean total hospital charges ($29,981 vs $36,745) and costs ($11,528 vs $13,426) were markedly less.

CONCLUSIONS

Compared with OSC for diverticulitis, LSC results in a more rapid return of bowel function and shortened hospital stay. Despite the greater operating room charges of LSC, the total hospital charges and costs are lessened.

Continuing hazards of the learning curve in laparoscopic cholecystectomy

Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy (LC). In open cholecystectomy (OC) the reported incidence of injury is less than 0.2 per cent. In LC, the aggregate reported experience, in many thousands of cases, is three or four times this number. Although "the learning curve" has been considered the principal factor in the heightened incidence of this complication with LC, there are hazards inherent in this new surgical modality that may never allow elimination of the increased risk of bile duct injury. As a sequel to an earlier report of 1200 cases of OC before the laparoscopic era from a single institution, this report deals with the next 2427 consecutive cases of LC from the same institution. In the first 1284 cases of LC, there were seven bile duct injuries (0.58%); in the ensuing 1143 cases there were six bile duct injuries (0.50%). The overall incidence nationwide is even higher, as evidenced by widespread reports of repair of bile duct injuries referred to major tertiary care centers. Routine operative cholangiography is of the utmost importance in the early recognition and immediate repair of ductal injuries. In 12 of the 13 cases reported here, early recognition and repair during the primary surgery resulted in a successful outcome.

Distribution of unlinked transpositions of a Ds element from a T-DNA locus on tomato chromosome 4

In maize, receptor sites for unlinked transpositions of Activator (Ac) elements are not distributed randomly. To test whether the same is true in tomato, the receptor sites for a Dissociation (Ds) element derived from Ac, were mapped for 26 transpositions unlinked to a donor T-DNA locus on chromosome 4. Four independent transposed Dss mapped to sites on chromosome 4 genetically unlinked to the donor T-DNA, consistent with a preference for transposition to unlinked sites on the same chromosome as opposed to sites on other chromosomes. There was little preference among the nondonor chromosomes, except perhaps for chromosome 2, which carried seven transposed Dss, but these could not be proven to be independent. However, these data, when combined with those from other studies in tomato examining the distribution of transposed Acs or Dss among nondonor chromosomes, suggest there may be absolute preferences for transposition irrespective of the chromosomal location of the donor site. If true, transposition to nondonor chromosomes in tomato would differ from that in maize, where the preference seems to be determined by the spatial arrangement of chromosomes in the interphase nucleus. The tomato lines carrying Ds elements at known locations are available for targeted transposon tagging experiments.

Complications of laparoscopic cholecystectomy in HIV and AIDS patients

We retrospectively evaluated the results of laparoscopic cholecystectomy in patients infected with the human immunodeficiency virus (HIV) with and without acquired immunodeficiency syndrome (AIDS). One thousand one hundred twenty-seven consecutive patients underwent laparoscopic cholecystectomy by our surgical group. Eighteen of these patients were known to be infected with the HIV virus; 6 were asymptomatic and 12 had AIDS. We reviewed the medical records of all HIV-positive individuals with regard to morbidity, mortality, and postoperative outcome following laparoscopic cholecystectomy. In the six HIV-patients without AIDS, five (83%) had improvement of symptoms postoperatively. There was one minor complication (17%). In contrast, only one of the 12 patients with AIDS had postoperative improvement of symptoms and eight (66%) had complications after surgery. There were four deaths (33%) within 30 days of surgery in this group. Only a small percentage of AIDS patients benefit from laparoscopic cholecystectomy. There is a significantly morbidity and mortality following this procedure in this group. Strategies to improve outcome are presented.

Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

OBJECTIVE

To evaluate treatments for common bile duct stones (CBDS).

DESIGN

Retrospective review of authors' case series.

SETTING

Large private metropolitan teaching hospital.

PATIENTS

All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography.

INTERVENTIONS

Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10).

MAIN OUTCOME MEASURES

Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization.

RESULTS

Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death.

CONCLUSIONS

For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

Germinal transpositions of the maize element Dissociation from T-DNA loci in tomato

We have analyzed the pattern of germinal transpositions of artificial Dissociation (Ds) transposons in tomato. T-DNA constructs carrying Ds were transformed into tomato, and the elements were trans-activated by crossing to lines transformed with a stabilized Activator (sAc) that expressed the transposase gene. The sAc T-DNA carried a GUS gene to monitor its segregation. The Ds elements were inserted in a marker gene so that excision from the T-DNA could be monitored. The Ds elements also carried a genetic marker that was intended to be used for reinsertion selection of the elements after excision. Unfortunately, this gene was irreversibly inactivated on crossing to sAc. Germinal excision frequencies of Ds averaged 15-40%, but there was large variation between and within plants. Southern hybridization analysis of stable transposed Ds elements indicated that although unique transpositions predominate, early transposition events can lead to large clonal sectors in the germline of developing plants and to sibling offspring carrying the same transposition event. Multiple germinal transpositions from three different loci were examined for uniqueness, and 15 different transpositions were identified from each of three T-DNA loci that carried a single independent Ds. These were mapped relative to the donor T-DNA loci, and for each locus 70-80% of the transposed elements were closely linked to the donor site.

Incidence of complications following laparoscopic hernioplasty

Smaller individual series on the outcome of laparoscopic hernioplasty techniques have been reported. This study reports on the complications of 3,229 laparoscopic hernia repairs performed by the authors in 2,559 patients. The TAPP (transabdominal preperitoneal) technique was the most frequently performed: 1,944 (60%). The totally preperitoneal technique was performed 578 (18%) times. The IPOM (intraperitoneal onlay mesh) repair was performed 345 (11%) times. The plug-and-patch technique was used 286 (9%) times and simple closure of the hernia defect without mesh was used in 76 (2%) repairs. Overall, there were 336 (10%) complications: 17 (0.5%) major and 265 (8%) minor. There were 54 (1.6%) recurrences, with a mean follow-up of 22 months. The TAPP technique had 19 (1%) recurrences and 141 (7%) complications. There were four bowel obstructions in this subgroup from herniation of small bowel through the peritoneal closure and trocar sites. The totally preperitoneal technique had no recurrence and 60 (10%) complications. The IPOM group had 7 (2%) recurrences and 47 (14%) complications. The plug-and-patch technique had 26 (9%) recurrences and 24 (8%) complications. The simple closure of the internal ring had 2 (3%) recurrences and 10 (13%) complications. Laparoscopic hernioplasty is not without complications. Laparoscopic hernioplasty is not without complications. Training, experience, and attention to technique will prevent some of these complications.