The buildup of an urge in obsessive-compulsive disorder: Behavioral and neuroimaging correlates

Obsessive-compulsive disorder (OCD) is highly heterogeneous. While obsessions often involve fear of harm, many patients report uncomfortable sensations and/or urges that drive repetitive behaviors in the absence of a specific fear. Prior work suggests that urges in OCD may be similar to everyday "urges-for-action" (UFA) such as the urge to blink, swallow, or scratch, but very little work has investigated the pathophysiology underlying urges in OCD. In the current study, we used an urge-to-blink approach to model sensory-based urges that could be experimentally elicited and compared across patients and controls using the same task stimuli. OCD patients and controls suppressed eye blinking over a period of 60 s, alternating with free blinking blocks, while brain activity was measured using functional magnetic resonance imaging. OCD patients showed significantly increased activation in several regions during the early phase of eyeblink suppression (first 30 s), including mid-cingulate, insula, striatum, parietal cortex, and occipital cortex, with lingering group differences in parietal and occipital regions during late eyeblink suppression (last 30 s). There were no differences in brain activation during free blinking blocks, and no conditions where OCD patients showed reduced activation compared to controls. In an exploratory analysis of blink counts performed in a subset of subjects, OCD patients were less successful than controls in suppressing blinks. These data indicate that OCD patients exhibit altered brain function and behavior when experiencing and suppressing the urge to blink, raising the possibility that the disorder is associated with a general abnormality in the UFA system that could ultimately be targeted by future treatments.

Functional neural mechanisms of sensory phenomena in obsessive-compulsive disorder

Sensory phenomena (SP) are aversive or uncomfortable sensations that accompany and/or drive repetitive behaviors in obsessive-compulsive disorder (OCD). Although SP are associated with significant distress and may respond less well to standard treatments than harm-related obsessions, little is known about their underlying neurobiology. The present study used functional magnetic resonance imaging (fMRI) to measure brain functioning related to severity of SP during a "body-focused" videos task designed to elicit activation in sensorimotor brain regions. Regression analysis examined the relationship between severity of SP and activation during task using permutation analysis, cluster-level corrected for multiple comparisons (family-wise error rate p < 0.05). The distribution of SP severity was not significantly different from normal, with both high- and low-severity scores represented in the OCD sample. Severity of SP was not correlated with other clinical symptoms in OCD including general anxiety, depression, or harm avoidance. When viewing body-focused videos, patients with greater severity of SP showed increased activity in the mid-posterior insula, a relationship that remained significant when controlling for other clinical symptoms, medication status, and comorbidities. At uncorrected thresholds, SP severity was also positively related to somatosensory, mid orbitofrontal, and lateral prefrontal cortical activity. These data suggest that SP in OCD are dissociable from other symptoms in the disorder and related to hyperactivation of the insula. Future work examining neural mechanisms of SP across different disorders (tics, trichotillomania) as well as with other imaging modalities will be needed to further understand the neurobiology of these impairing symptoms.

High-dose ondansetron reduces activation of interoceptive and sensorimotor brain regions

Several psychiatric disorders involve abnormalities of interoception and associated neural circuitry centered on the insula. The development of interventions modulating interoceptive circuits could lead to novel treatment approaches for these disorders. The 5-HT3 receptor antagonist ondansetron is a good candidate for the modulation of interoceptive circuits, as 5-HT3 receptors are located abundantly on sensory pathways and ondansetron has shown some clinical utility in disorders characterized by sensory and interoceptive abnormalities. The present study tested the ability of three different doses of ondansetron to engage neural regions involved in interoception to determine the drug's utility as a therapeutic agent to target circuit abnormalities in patients. Fifty-three healthy subjects were randomized to receive a single 8-mg (n = 18), 16-mg (n = 17), or 24-mg (n = 18) dose of ondansetron and placebo before MRI scanning on separate days. Subjects performed an fMRI task previously shown to engage interoceptive circuitry in which they viewed videos depicting body movements/sensation and control videos. The results revealed a highly significant relationship between dosage and activation in bilateral insula, somatosensory and premotor regions, cingulate cortex, and temporal cortex for control but not body-focused videos. These effects were driven by a robust reduction in activation for ondansetron compared to placebo for the 24-mg group, with weaker effects for the 16-mg and 8-mg groups. In conclusion, high-dose ondansetron reduces activation of several areas important for interoception, including insula and sensorimotor cortical regions. This study reveals the potential utility of this drug in modulating hyperactivity in these regions in patients.

Look before you pack: key point in epistaxis management

We report a patient with epistaxis who used cotton wool to pack his nose before reaching the hospital, and underwent further packing in the accident and emergency department, which probably pushed the cottonwool further back. This led to the formation of foreign body granuloma inside the nasal cavity. It is difficult to examine the nose without proper equipment and experience, and the examination is more difficult in the presence of active bleeding to find a foreign body such as cotton wool. Hence, it is important to ask the patient about any temporary pack they have used in the nose and to look for and remove it before inserting a proper pack. It is also important for trainees to have a better understanding of the different levels of management of epistaxis. Hence, we propose the term "epistaxis management ladder" for easy understanding of the treatment of epistaxis.

How we do it: A series of 114 primary pharyngeal space neoplasms

Primary parapharyngeal space tumours are exceedingly rare. We present a series of 114 parapharyngeal space tumours, the second largest in the literature. The most frequent benign tumours were pleomorphic adenoma (34) and paraganglioma (33); the commonest malignancies were of salivary gland origin (12). The 5- and 10-year survival for benign tumours was 100%. The 5- and 10-year survival for malignancies was 93% and 57% respectively. The importance of long-term follow-up is evidently crucial.

A safe and cost-effective method of removal of obstructed pharyngeal foreign body in the accident and emergency department

Foreign body obstruction at the level of the cricopharynx is not an uncommon presentation in the accident and emergency department. If this is visualised with a fibro-optic endoscope, it can be safely removed in the emergency department with the help of short acting inhalational anaesthesitic agents such as sevoflurane. This method is safe and effective and also saves valuable operating theatre resources.

Idiopathic lymphoepithelial cyst of the parapharynx masquerading as peritonsillar abscess

We present a case of a 38-year-old man who was referred to us with a right-sided quinsy. However he was found to have a large lympho-epithelial cyst in his right parapharynx mimicking the signs of a quinsy to the unsuspecting eye. We describe this case to illustrate an unusual cause of a swelling of the lateral pharyngeal wall.

Infrared transtympanic temperature measurement and otitis media with effusion

Body temperature is an important clinical measurement. It can be estimated by sublingual, rectal, axillary or skin measurement. Pulmonary artery temperature measurement is the gold standard in the research setting, but is obviously inapplicable for routine clinical use. Infrared estimation of core temperature at the tympanic membrane has been proposed as an effective and accurate method. We investigate whether the common condition of childhood otitis media with effusion (OME) interferes with this mode of body temperature measurement. Ninety-five children undergoing grommet tube insertion were assessed preoperatively by axillary and transtympanic routes. The presence or absence of middle ear fluid was noted at the time of surgery. Analysis of the data showed no influence of OME on the measurement of body temperature by the transtympanic route compared with axillary measurement.

Isolated hypoglossal nerve palsy due to internal carotid artery dissection

A case of an isolated hypoglossal nerve palsy is reported. The differential diagnosis is discussed, in the context of the requirement for careful scrutiny of the entire course of the hypoglossal nerve on imaging, to detect underlying pathology remote from the tongue, and to avoid unnecessary invasive diagnostic procedures prompted by the appearance of a 'pseudomass' of the weak tongue both clinically and radiologically.

Role of a home care team in paediatric day-case tonsillectomy

The feasibility of paediatric day-case tonsillectomy (PDCT) depends on its safety and acceptance by parents and patients. The purpose of our retrospective study of paediatric day-case tonsillectomy was to review the role of the home care team (HCT) in improving the safety and acceptance of the procedure. Between January 1997 and June 1999, 352 consecutive children underwent day-case tonsillectomy. The notes and HCT assessment sheets were reviewed for telephone calls made by HCT or by parents, home visit by HCT, types of complication and their outcome. The primary haemorrhage rate was 0.6 per cent. The effective day-case rate was 97 per cent. The unplanned admission rate was three per cent. The HCT visited about 25 per cent of patients at home. We conclude that paediatric day-case tonsillectomy is associated with high morbidity and considerable parental anxiety that can be dealt with by timely reassurance, support and advice by a dedicated HCT.