Inadequate cerebral perfusion is an unlikely cause of perioperative stroke

The purpose of this study was to determine the importance of hypoperfusion ischemia as a cause of stroke during carotid endarterectomy (CEA). A retrospective analysis of 128 consecutive CEA procedures were examined in patients at risk for hypoperfusion ischemia, namely, patients with occlusion of the contralateral carotid artery. All procedures were performed under general anesthesia without the use of a temporary indwelling shunt. Sixty-one percent of patients had cerebrovascular symptoms preoperatively and 39% were asymptomatic. The degree of stenosis of the carotid artery was 80%-99% in 67% (86/128) of patients, 60%-79% in 25% (32/128), 20%-59% in 7% (9/128), and 0-19% in 0.8% (1/128). The perioperative mortality was 0.8% (1/128), the incidence of permanent neurologic morbidity was 1.6% (2/128), and the incidence of transient neurologic morbidity was 3.9% (5/128). In conclusion, these data suggest that hypoperfusion ischemia is a rare cause of stroke during CEA even in patients with occlusion of the contralateral carotid artery and that CEA can be performed safely even in patients with contralateral occlusion without the use of a temporary indwelling shunt.

The Patient-Staff Community Meeting: Old Tools, New Rules

1. Psychiatric inpatient units with rapid turnover and acutely ill clients are vulnerable to the development of antitherapeutic trends, including destructiveness, disorganization, dysphoria, deviance, and dependency. 2. Inpatient therapists can apply the principles and techniques of milieu therapy, with certain modifications, to establish a therapeutic environment. 3. The patient-staff community plays a central role in this transformation, if it is structured to promote experiences of safety, order, support, involvement, and validation. 4. To accomplish these goals, the leaders of the meeting should establish clear rules and healthy norms, energize and guide participation, and focus discussion on topics relevant to unit events and to the processes of treatment and recovery.

Spectral and topographic analysis of EEG in schizophrenic patients

The authors performed spectral analysis of electroencephalograms (EEG), recorded awake, with eyes closed, in 13 patients with schizophrenia and 9 age-matched individuals without psychiatric diagnosis. We tested several possible parameterizations of the data, and two data-reduction strategies; these yielded similar results. Comparison of the two groups revealed a relative increase in alpha frequency activity in the frontal regions in the patient group. The authors believe that this finding is consistent with data from neuropsychologic tests, metabolic imaging studies, and evoked potential studies that suggest impaired activation of frontal brain areas in patients with schizophrenia.

Group treatment assignment for outpatients with schizophrenia: integrating recent clinical and research findings

Many mental health clinics rely heavily on group treatment in the outpatient care of individuals with schizophrenia. Groups are used because they economize clinician time and provide social interaction for isolated patients. Empirical evidence suggests that groups, combined with medication, are at least as effective as other common treatments. Many group formats and techniques have been used. Choices are often based on pragmatism or inclination, rather than theory or experiment. The authors review recent findings from research on the neurobiology of schizophrenia, its natural history, and the impact of psychosocial factors in its course and treatment. From these findings, they elaborate research based principles for outpatient group therapy in schizophrenia. They describe three distinct formats for group treatment, and delineate the scope of use for each. Finally, they propose guidelines for assignment of patients to appropriate group treatments.

Inpatient group processes parallel unit dynamics

The authors conducted a quantitative examination of parallels between milieu and therapy group dynamics on a short-term inpatient unit. The Ward Atmosphere Scale was used to assess the milieu, and the Group Climate Questionnaire-S to measure processes in key groups. Assessments were made by patients and staff once each week for 10 months. The authors found clear parallels between ward and therapy group processes. The parallels reflected the impact of patterns utilization of the unit, its treatment philosophy, and the emotional dynamics of its constituents. Examination of these associations also revealed limitations of the treatment setting, clarified the potential impact of particular staff interventions, and demonstrated biases in the rating methods. Study of parallel process on the psychiatric unit is a rich source of information on the nature of inpatient treatment.

Akathisia: clinical phenomenology and relationship to tardive dyskinesia

Akathisia and tardive dyskinesia (TD) are disorders of movement that are often associated with administration of antipsychotic medication. We surveyed 196 outpatients in a schizophrenia clinic, all receiving antipsychotic medication, for the presence of these disorders. Clinical global ratings of akathisia were reliable. Akathisia was found in 36% of patients, and TD in 23.5%. Akathisia was disproportionately common in patients receiving high-potency neuroleptics. The data affirmed recent revisions in the dose-equivalence formulas used with fluphenazine decanoate. Akathisia and TD did not seem to be interrelated. Because akathisia is common and often limits medication dose and contributes to noncompliance, psychiatrists must take this into account when prescribing antipsychotic medication.

Imaging of brain electrophysiologic activity: applications in psychiatry

Recent advances in computer technology make it relatively easy to generate color images representing the electrophysiologic activity of the brain. Because of the visual appeal of the images, and their similarity to computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) scans, there has been wide interest in these methods. Thorough understanding of these techniques is necessary to appreciate their strengths and limitations, and their proper application. This article explains the types of studies that are usually done, compares these methods with other imaging techniques, outlines their limitations, summarizes the literature on their use in psychiatry, and describes clinical situations in which these tests may be useful. This information will help the reader interpret clinical reports and research studies that employ these methods, evaluate representations made by commercial vendors of imaging systems, and understand the role these tests can play in his or her daily clinical practice.

Change in haloperidol level due to carbamazepine--a complicating factor in combined medication for schizophrenia

Serum haloperidol levels were measured in patients who received haloperidol alone and, subsequently, haloperidol in combination with carbamazepine or lithium carbonate. Haloperidol levels and the level- dose ratios dropped about 50% in patients receiving carbamazepine. They remained the same in most patients receiving lithium carbonate. One patient receiving added carbamazepine experienced worsening of symptoms; this was associated with a drop in serum haloperidol level. Two other patients receiving added carbamazepine showed significant symptom reduction, although they also sustained drops in serum haloperidol levels. It is not clear whether these two individuals benefited from a primary antipsychotic effect of carbamazepine or from reduction of "toxic" haloperidol levels. Serum levels of antipsychotic medication should be monitored carefully when these medications are prescribed in combination with carbamazepine.

Adapting milieu approaches to acute inpatient care for schizophrenic patients

Classic therapeutic community or milieu therapy techniques are not applicable in many contemporary acute-treatment settings, which emphasize crisis intervention, short stays, psychotropic medication, and cost containment. However, milieu techniques can be integrated with an understanding of biological and psychosocial factors to provide a framework for the acute, short-term treatment of schizophrenic patients. After reviewing recent biological and psychosocial research, the authors outline three principles for incorporating such research with milieu techniques: creating a holding environment, developing a graduated therapeutic program, and focusing on common patient needs. Application of these principles in a short-stay setting will provide an intensely supportive treatment environment that allows the use of many different therapies and modulates stresses on staff.

Musical hallucinations following removal of a right frontal meningioma

Images

Topographic maps of brain electrical activity--pitfalls and precautions

Topographic mapping of brain electrical activity is a popular, powerful, and potentially misleading technique. The map lies at the end of a long chain of physiological, technical, electronic, and mathematical processes and is vulnerable to artifact, error, and distortion at many points. Close attention must be paid to data collection parameters, subject cooperation, minimization of artifact, limitations of resolutions, selection, and transformation of parameters for display, and map generation strategy to yield an accurate, physiologically interpretable map. Review of the data at each step of analysis, from the paper electroencephalogram (EEG) to sets of maps on video display, may be necessary for optimum understanding. Development of more sophisticated qualitative and quantitative concepts of "normal" physiology is needed. These improvements in electrophysiological data analysis demand, rather than obviate, sophistication on the part of the user.

Use and Modifications in Group Psychotherapy with Chronic Schizophrenic Outpatients

The authors have presented a framework for group psychotherapy with chronic schizophrenic outpatients which is based on belief that these patients can engage in moderately intensive insight-oriented therapy. The functional deficits and the interpersonal needs of these patients have been identified, and a strategy of intervention has been developed to ameliorate these deficits and facilitate gratification of these needs. Modifications in traditional group approaches are necessary for these groups to be a success. These include alterations in: 1) the group contract, 2) role and tasks of the therapists, and 3) use of special techniques. The authors believe that use of these techniques, informed by genuine interest in and empathy for these patients, will lead to a successful group experience for all.

Carotid artery surgery without a temporary indwelling shunt. 1,917 consecutive procedures

One thousand nine hundred seventeen consecutive carotid artery operations were performed in which the carotid artery was clamped for as long as necessary to accomplish a revascularization procedure. Those patients adversely affected by failure to use a shunt were identified. Results of a statistical analysis of stroke morbidity when compared with the literature show that the use of an intraoperative temporary shunt does not offer improved results in carotid artery surgery.