Acute Exertional Bilateral Thigh Compartment Syndrome in a Patient with Rhabdomyolysis After Spin Class: A Case Report

CASE

A healthy 24-year-old woman developed rhabdomyolysis and acute bilateral thigh compartment syndrome after 10 minutes of spin class. She was successfully managed with early recognition, aggressive fluid resuscitation, and prompt bilateral surgical decompressive fasciotomy.

CONCLUSION

Rhabdomyolysis with acute compartment syndrome is a rare but devastating combination of conditions. A high suspicion for rhabdomyolysis and progression to acute compartment syndrome is warranted for any patient presenting with increasing pain even with a limited history of trauma or exertion. Early recognition and medical and surgical treatment are paramount to preventing permanent damage.

How Are Radial Height and Radial Shortening Defined in the Treatment of Distal Radius Fractures? A Critical Review

BACKGROUND

Radial height is a radiographic parameter used to guide the treatment of distal radius fractures. However, it is often used synonymously with other terms, and there are substantial discrepancies in its measurement/definition. These discrepancies can alter the measurement of radial height and affect treatment decisions. The purpose of this review is to identify the different definitions of radial height in the literature relevant to distal radius fractures.

METHODS

A literature review was conducted in the PubMed/MEDLINE database from inception to 2022. Full-length, English-language studies that pertained to distal radius fractures and reported radial height as a recorded measurement were included. The method of radial height measurement (definition) was extracted from included studies. Level of evidence was determined by the Oxford Centre for Evidence-based Medicine Levels of Evidence tool.

RESULTS

A total of 385 studies were identified. Of these, 183 (47.5%) did not provide a definition for radial height. Of the studies that defined radial height, 50.9% (103/202) measured radial height from the radial styloid to the distal ulna, 10.9% (22/202) measured from the radial styloid to the distal radius, and 29.2% (59/202) were "other" definitions.

CONCLUSIONS

There is substantial discrepancy in the way that radial height is measured and reported. We advocate for a standardized measurement of radial height (synonymous with radial length) from the radial styloid to the distal ulnar articular surface. Radial shortening is a different measurement and requires comparison with a reference value.

Patient Perceptions of COVID-19 Precautions and Their Effects on Experiences With Hand Surgery

Purpose

The purpose of this study is to evaluate patient perceptions of COVID-19 precautions and how these precautions have affected their hand and upper extremity surgery experience.

Methods

We sent an 18-item survey to 1,213 patients who underwent elective hand and upper extremity surgery at 1 academic institution from October 2020 to January 2021. The survey consisted of questions related to patient demographics, treatment delays due to COVID-19, and patient perceptions of COVID-19 precautions. Descriptive statistics were performed to analyze the survey responses. Responses for patients aged 18–50 and 51+ were compared using a chi-square analysis for categorical variables and a Student t-test for continuous variables.

Results

Out of 1,213 invitations, 384 survey respondents completed the survey (31.6%). Of the respondents, 16.8% reported delaying medical treatment for an average of 123.2 days because of COVID-19. The preventative measures were found to be adequate by 95% of patients. Only 2.6% of patients reported experiencing surgical delays due to preoperative COVID-19 testing or other COVID-19-related precautions. COVID-19 testing was seen as necessary by 88% of patients, and 74% did not find COVID-19 testing to be a barrier to their surgery. Patients aged 51+ were more likely to delay seeking medical treatment than younger patients (19.3% vs 9.1%, respectively). Furthermore, those that did delay seeking treatment waited longer on average than their younger counterparts (136.1 vs 72.9 days, respectively).

Conclusions

In conclusion, patients undergoing hand and upper extremity surgery typically do not find COVID-19 precautions to be a significant barrier to care and understand their importance. Despite this, many patients, particularly older ones, are delaying medical care for extended periods of time. It is important for hand surgeons to acknowledge their patients’ perspectives and work to educate patients on evolving surgical safety guidelines.

Clinical relevance

Patient perspectives of current COVID-19 precautions can help inform hand surgeons on areas for continued patient education.

Septic Arthritis of the Pediatric Wrist: A Case Report and Review of the Literature

Septic arthritis of the wrist in pediatric patients is a rare diagnosis and is not well described in the literature. We present a case of a 4-month old patient with monoarticular septic arthritis of the wrist treated with surgical drainage and antibiotics. Although a rare diagnosis, septic arthritis of the wrist should be considered in patients with pseudoparalysis of the upper extremity and systemic signs of inflammation. Prompt diagnosis and treatment is critical to prevent permanent damage to the joint. Further data is needed to describe the epidemiology, microbiology, diagnostic findings and treatment of septic arthritis of the pediatric wrist.

Transvenous pacemaker placement: left lateral decubitus position and wireless digital radiography

A patient presented with symptomatic third degree atrioventricular block requiring emergency transvenous pacemaker placement. During the procedure, wireless digital radiographs tracked the position of the pacemaker electrode, which repeatedly missed the target right ventricle. The patient was then rolled to left lateral decubitus position and the electrode was advanced into the right ventricle, achieving electrical capture, hemodynamic stability, and symptom resolution. We review the published literature on transvenous pacemaker placement and identify two innovations: left lateral decubitus position to facilitate catheter placement and wireless digital radiography for procedure guidance.

Decoherence of a single-ion qubit immersed in a spin-polarized atomic bath

We report on the immersion of a spin qubit encoded in a single trapped ion into a spin-polarized neutral atom environment, which possesses both continuous (motional) and discrete (spin) degrees of freedom. The environment offers the possibility of a precise microscopic description, which allows us to understand dynamics and decoherence from first principles. We observe the spin dynamics of the qubit and measure the decoherence times (T(1) and T(2)), which are determined by the spin-exchange interaction as well as by an unexpectedly strong spin-nonconserving coupling mechanism.

Effects of rivastigmine on cognitive function in patients with traumatic brain injury

OBJECTIVE

To compare the efficacy and safety of rivastigmine (3 to 6 mg/day) vs placebo over 12 weeks in patients with traumatic brain injury and persistent cognitive impairment.

METHODS

This prospective, randomized, double-blind, placebo-controlled study was conducted in 157 patients at least 12 months after injury. The primary efficacy measures were the Cambridge Neuropsychological Test Automated Battery (CANTAB) Rapid Visual Information Processing (RVIP) A' subtest and the Hopkins Verbal Learning Test (HVLT). The primary efficacy outcome was the proportion of patients who demonstrated 1.0 SD or greater improvement from baseline at week 12 on CANTAB RVIP A' or HVLT.

RESULTS

The percentage of responders at week 12 on either the CANTAB RVIP A' or HVLT was 48.7% for rivastigmine and 49.3% for placebo (p = 0.940). Furthermore, for the overall study population, there were no significant differences for any of the secondary efficacy variables. In a subgroup of patients with moderate to severe memory impairment (n = 81), defined as 25% impairment or greater on HVLT at baseline, rivastigmine was significantly better than placebo for a number of measures, including the proportion of HVLT responders and CANTAB RVIP mean latency.

CONCLUSIONS

Rivastigmine was safe and well tolerated in patients with traumatic brain injury with cognitive deficits. Rivastigmine shows promising results in the subgroup of patients with traumatic brain injury with moderate to severe memory deficits.

The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiologic Catchment Area Study

PRIMARY OBJECTIVE

To determine the association of report of any history of head injury with loss of consciousness or confusion and a lifetime diagnosis of psychiatric disorder in a general population.

RESEARCH DESIGN

A probability sample of adults from the New Haven portion of the NIMH Epidemiologic Catchment Area programme were administered standardized and validated structured interviews. The main outcome measures were lifetime prevalence of psychiatric disorders and suicide attempt in individuals with and without a history of traumatic brain injury.

MAIN OUTCOMES AND RESULTS

Among 5034 individuals interviewed, 361 admitted to a history of severe brain trauma with loss of consciousness or confusion (weighted rate of 8.5/100). When controlling for sociodemographic factors, quality of life indicators and alcohol use, risk was increased for major depression, dysthymia, panic disorder, OCD, phobic disorder and drug abuse/dependence. In addition, lifetime risk of suicide attempt was greater in those who had suffered head injury.

CONCLUSION

Individuals with a history of traumatic brain injury have significantly higher occurrence for psychiatric disorders and suicide attempts in comparison with those without head injury and have a poorer quality of life. Future studies should examine the nature of this relationship, focusing on the severity of the brain injury and the temporal contiguity of the brain injury and psychiatric disorder.

Axis II psychopathology in individuals with traumatic brain injury

PRIMARY OBJECTIVES

To determine the frequency and nature of post-TBI personality disorders (PDs) in a community-based sample of individuals with TBI.

RESEARCH DESIGN

One hundred individuals with TBI were administered a structural clinical interview to determine Axis II psychopathology. METHODS OF PROCEDURES: The Structured Clinical Interview for DSM-IV Personality Disorders, Clinician Version (SCID II) was used to determine 12 Axis II personality disorders. SCID II questions were modified so that symptom onset could be rated as occurring pre-injury vs. post-TBI. Data were analysed using student T-tests, chi-square analysis and one way analyses of variance.

OUTCOMES AND RESULTS

Pre-TBI PDs were diagnosed in 24% of the sample; antisocial PD and obsessive-compulsive PD were the most common diagnoses. Post-TBI, 66% of the sample met criteria for at least one PD, with PDs independent of TBI severity, age at injury, and time since injury. The most common post-TBI PDs were: borderline, avoidant, paranoid, obsessive-compulsive and narcissistic. Men were more likely to be diagnosed with antisocial PD and narcissistic PD. Individuals with pre-TBI PDs were at greater risk of acquiring additional psychopathology post-TBI. Personality traits endorsed by more than 30% of the sample post-TBI reflected loss of self-confidence, attempts to cope with cognitive and interpersonal failures and negative affect.

CONCLUSION

These findings argue against a specific TBI personality syndrome, but rather a diversity of personality disorders reflective of the persistent challenges and compensatory coping strategies developed by individuals post-TBI. Prospective need for clinical assessment, pro-active education and focused treatment approaches are discussed.

Propranolol treatment of chronically hospitalized aggressive patients

Violent behavior in psychiatric patients may result in long-term hospitalization. There is no FDA-approved psychopharmacologic treatment for aggression. In this study, 20 chronically aggressive hospitalized patients were administered 1 week of placebo followed by an open trial of increasing doses of propranolol. Patients who had an equivocal or definite clinical response were entered into an open add-on double-blind discontinuation study phase. Aggressive behavior was objectively documented throughout the study. After the open phase of the study, 7 patients had a greater than 50% decrease in aggressive behavior. Four patients entered the double-blind discontinuation phase. The clinical course of 3 of those patients was consistent with the positive response to propranolol. The results of this study are consistent with a therapeutic effect of propranolol in some patients with aggressive behavior. Further studies are indicated.

Vasopressin treats the persistent feeling of coldness after brain injury

In this pilot study, 6 patients who complained of persisting coldness after brain injury were treated with intranasal vasopressin (DDAVP) twice daily for 1 month. Response was assessed after 1 month of treatment, DDAVP was discontinued, and response was reassessed 1 month later. Five of the 6 patients had a dramatic response to DDAVP, as soon as 1 week after initiating treatment, and no longer complained of feeling cold. Response persisted even after discontinuation of treatment. Patients denied any side effects from treatment with DDAVP. The experience of persisting coldness can respond dramatically to brief treatment with intranasal DDAVP. The authors discuss possible mechanisms of action to explain this phenomenon.

Ewing's sarcoma presenting as a posterior mediastinal mass: a lesson learned

Thoracic vertebral body hemicorpectomy and chest wall resection was performed in a 17-year-old male patient with a posterior mediastinal tumor thought to be neurogenic in origin. No preoperative tissue diagnostic endeavor was made. Final pathologic diagnosis showed this tumor to be Ewing's sarcoma. This communication alerts the thoracic surgeon to the need for definitive diagnosis of posterior mediastinal masses with vertebral body involvement, particularly in children. Induction chemotherapy is the accepted standard of management of these sarcomas.

The Overt Agitation Severity Scale for the objective rating of agitation

Two studies tested the reliability and validity of the Overt Agitation Severity Scale (OASS), a new instrument developed to define and objectively rate the severity of agitated behavior. The authors postulate that agitation should be conceptualized as vocal and motor behaviors on a continuum of expressions that extends from anxiety to aggression. Content validity through expert agreement was achieved in the development of test construction over a 2-year period. Results of two pilot studies (n = 25 and n = 14 subjects) established the reliability and validity of the OASS to measure agitation severity. The OASS differs from other agitation scales in that it confines its rating exclusively to observable behavioral manifestations of agitation.

Laparoscopic-guided biopsy of pancreatic transplant allograft

Percutaneous and transcystoscopic transplanted pancreatic graft biopsy have now become the best methods in diagnosing graft rejection and dysfunction. We report our technique of laparoscopic pancreatic graft biopsy in a case not amenable to standard trancystoscopic or percutaneous biopsy.

CASE REPORT

A 44-year-old man underwent enteric conversion of a previous combined bladder-drained kidney-pancreas transplantation for repeated episodes of dehydration. Complaints of polyuria and polydipsia necessitated biopsies of the grafts to rule out graft rejection. The ultrasound of the pancreas, however, showed multiple bowel loops overlying the graft preventing percutaneous biopsy. The patient was taken for laparoscopic-guided pancreatic graft biopsy.

DISCUSSION

Enteric-converted pancreatic grafts are not amenable to transcystoscopic biopsy. These grafts are often covered with loops of small bowel preventing ultrasound-guided percutaneous biopsy. Until recently, open laparotomy was performed to biopsy these grafts. We present our method of laparoscopic-guided pancreatic graft biopsy as an alternative to open laparotomy.

CONCLUSIONS

Laparoscopic guided biopsy for pancreatic allograft transplantation is a safe and effective alternative to open laparotomy and should be considered when percutaneous biopsy is hazardous or not possible.

Differences in the anatomic distribution of immediate-early gene expression in amygdala and angular bundle kindling development

Kindling is a model in which fleeting changes of neuronal activity produce a lifelong modification of neuronal structure and function in the mature nervous system. Immediate-early genes (IEGs) such as c-fos have been implicated as a causal link in the chain of molecular events coupling fleeting pathologic activity to lasting hyperexcitability. Identification of the brain structures exhibiting IEG expression during the evolution of kindling is necessary to guide investigations of the phenotypic consequences. We used in situ hybridization histochemistry to identify the structures exhibiting expression of multiple IEGs during the evolution of amygdala kindling and compared this to the pattern following angular bundle kindling. The principal findings included that: (1) generalized limbic and clonic motor (class 5) kindled seizures evoked by stimulation of one amygdala induced the expression of IEGs in a small subset of limbic structures with remarkable symmetry between the two hemispheres; (2) the anatomic extent of seizure-evoked expression of c-fos mRNA expanded progressively following focal limbic and motor (classes 0-3) seizures during the development of amygdala kindling; c-fos mRNA was detected first ipsilaterally in AM, ACO, and PC and with higher-class seizures in hippocampal formation and homologous structures contralaterally, and (3) class 5 seizures evoked by stimulation of two different sites in the limbic system (amygdala or angular bundle) induced IEG expression in distinct but partially overlapping anatomic structures. We propose that synaptic activation of glutamate receptors contributes to the expression of these diverse IEGs throughout the forebrain. The findings provide a constellation of anatomic structures in which to investigate the structural and functional consequences of IEG expression.

Coronary vasodilation by isoflurane. Abrupt versus gradual administration

BACKGROUND

Under certain circumstances, isoflurane is associated with coronary artery vasodilation. The objective of the current study was to ascertain whether the rate of administration of isoflurane influences its vasodilating effect in the coronary circulation.

METHODS

Seven open-chest dogs anesthetized with fentanyl and midazolam were studied. The left anterior descending coronary artery was perfused via either of two pressurized (80 mmHg) reservoirs; reservoir 1 (control) was supplied with arterial blood free of isoflurane, and reservoir 2 was supplied with blood from an extracorporeal oxygenator, which was provided with 95% O2/5% CO2 gas that passed through calibrated vaporizer. Coronary blood flow (CBF) was measured with Doppler flow transducer. In each dog, isoflurane was administered according to two protocols; abrupt (isoflurane-A) or gradual (isoflurane-G). In isoflurane-A, the left anterior descending coronary artery was switched from reservoir 1 to reservoir 2 after the latter was filled with blood previously equilibrated with 1.4% (1 MAC) isoflurane. In isoflurane-G, the left anterior descending coronary artery was switched to reservoir 2 with vaporizer set at 0% isoflurane; then the vaporizer was adjusted to 1.4% isoflurane, which produced a gradual increase in isoflurane concentration within reservoir 2 that reached a level equivalent to that in isoflurane-A (as evaluated by gas chromatography) by 30 min. CBF during maximally dilating, intracoronary infusion of adenosine served as a reference to assess effects of isoflurane.

RESULTS

Isoflurane-A caused marked increases in CBF, which, at constant perfusion pressure, reflected pronounced reductions in vascular resistance. These increases in CBF were 80% of those with adenosine. Although isoflurane-G also caused increases in CBF, the increases were only 45% of those caused by isoflurane-A.

CONCLUSIONS

The current findings demonstrate that the extent of coronary vasodilation by isoflurane was not dependent only on its blood concentration but also on the rate at which this blood concentration was achieved; a gradual increase in blood concentration blunted the vasodilator effect. Differences in the rate of administration of isoflurane likely contributed to its widely variable coronary vasodilating effects in previous studies.

Contribution of nitric oxide to coronary vasodilation during hypercapnic acidosis

The present study was performed to evaluate the role of nitric oxide (NO) in coronary vasodilation during hypercapnic acidosis (HC). The left anterior descending coronary arteries of 17 anesthetized, open-chest dogs were perfused with normal arterial blood or with arterial blood equilibrated in an extracorporeal circuit with 90% O2-10% CO2 [arterial carbon dioxide tension (PaCO2) 72 +/- 3 mmHg, arterial pH 7.16 +/- 0.02]. Coronary perfusion pressure (CPP) was initially set at 100 mmHg. Coronary blood flow (CBF) was measured with a Doppler transducer. Studies were conducted under constant-pressure (variable CBF; n = 13) and constant-flow (variable CPP) conditions (n = 4). Steady-state changes in CBF (or CPP) during HC and during intracoronary infusions of acetylcholine (ACh, 20 micrograms/min), an endothelium-dependent vasodilator, and sodium nitroprusside (SNP, 80 micrograms/min), an endothelium-independent vasodilator, were compared before and after intracoronary infusion of a NO synthase inhibitor, either NG-nitro-L-arginine methyl ester (L-NAME, 4.5 mg) or NG-monomethyl-L-arginine (L-NMMA, 30 mg). Under constant pressure, L-NAME blunted increases in CBF by HC (274 +/- 32 vs. 113 +/- 24%) and ACh (400 +/- 43 vs. 68 +/- 17%), whereas increases in CBF by SNP were not significantly affected (207 +/- 34 vs. 186 +/- 18%). Results with L-NMMA were similar. Under constant flow, L-NAME attenuated decreases in CPP by HC and ACh, whereas it had no significant effect on decreases in CPP by SNP. In conclusion, HC elicits release of NO from coronary vascular endothelium via a direct effect rather than secondary to an increased flow rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacologic approach to management of agitation associated with dementia

Dementia is a complex syndrome associated with cognitive impairment, personality change, and behavioral disturbance. Behavioral symptoms frequently present the greatest challenge for caregivers and are often the determining factor in institutional placement. Determining the need for pharmacologic treatment of an agitated patient requires considering the full range of biopsychosocial variables and ultimately involves assessing the risks and benefits of the medications selected for the patient. In this article, the phenomenology of agitation is reviewed along with the pharmacologic treatment of agitation in patients with dementia, including the use of benzodiazepines, neuroleptics, beta-adrenergic-blocking agents, serotonergic agents, carbamazepine, and lithium.

Evaluation in an inpatient setting of DTREE, a computer-assisted diagnostic assessment procedure

This study examined the procedural validity of DTREE, a microcomputer-based expert system that guides the user through the diagnostic logic of DSM-III-R. A DTREE-guided DSM-III-R diagnosis of 20 inpatients (made by the treating clinician) was compared with a "standard" diagnosis made simultaneously during a weekly 2-hour case conference consisting of a presentation by the treating clinician and other staff, a chart summary, and the administration of the Structured Clinical Interview for DSM-III-R (SCID), and culminating in a group consensus diagnosis. The kappa agreements were .80 for schizophrenia (N = 10), .83 for major depression (N = 3), and -.08 to 1.00 for other disorders. These results suggest that DTREE can produce valid assessments, at least in an acute setting of primarily patients with schizophrenia.

Pharmacological and behavioral treatments for aggressive psychiatric inpatients

OBJECTIVE

Because aggressive behaviors of psychiatric patients may be caused by environmental or biological factors, treatment plans that incorporate medication and behavior therapies are the most effective. The authors review research on pharmacological and behavioral treatments for aggressive patients and present a decision tree for use on behavioral units to direct treatment of such patients.

METHODS

The empirical literature was searched for studies of pharmacological and behavioral interventions that have been shown to have some value for treating this problem.

RESULTS AND CONCLUSIONS

Psychiatrists must proceed cautiously because no medication has been approved by the Food and Drug Administration specifically for treatment of aggression. Antipsychotics, lithium, antidepressants, sedatives, anxiolytics, anticonvulsants, opiate antagonists, and beta blockers have been used, often depending on the etiology of the aggression, such as head injury or dementia. Although some drugs such as buspirone and propranolol show promise; side effects must be monitored. Three behavioral strategies have effectively reduced aggression in the inpatient milieu. The token economy is perhaps the most comprehensive behavioral tool for producing a well-structured milieu. Aggression replacement strategies help patients learn alternative responses. Decelerative techniques teach strategies that enable the patient to reduce aggression quickly. The authors describe a decision tree to guide decisions about pharmacological and behavioral treatments of aggression depending on where in the course of the disorder patients exhibit difficulty.

Neuropsychiatric aspects of adult-onset Tay-Sachs disease: two case reports with several new findings

Deficiency of hexosaminidase A causes the GM2 gangliosidosis known as Tay-Sachs disease. It is now known that this condition has several late-onset variants that cause numerous neuropsychiatric disturbances. Early recognition is important because treatment with phenothiazines and heterocyclic antidepressants may worsen the course. The authors report two cases with several new findings, including prominent psychiatric symptoms without psychosis early in the course of the illness.

Spinal subdural hematoma formation following ventriculoperitoneal shunting for hydrocephalus. Case report

A case of a 14-year-old girl who developed a spinal subdural hematoma after placement of a ventriculoperitoneal shunt is presented. Such a complication has not been previously reported. We believe that this represented an extension of intracranial subdural hematoma fluid into the spinal subdural space.

Antiepileptogenic effects of conventional anticonvulsants in the kindling model of epilespy

We sought to determine whether the clinically effective anticonvulsant drug valproate exhibited antiepileptogenic properties in the kindling model (we use the term anticonvulsant to mean suppression of seizure, and antiepileptogenic to mean suppression of development of epilepsy). We compared and contrasted valproate with two other anticonvulsant drugs, phenobarbital and carbamazepine. We investigated the effects of these drugs on the development of kindling, that is, the number of stimulation-induced afterdischarges required to induce enhanced seizure susceptibility in rats. Valproate exhibited powerful antiepileptogenic effects as evident in a dose-dependent increase in the number of afterdischarges required to induce kindling. These effects were not due to retained valproate or an active metabolite merely masking the expression of kindled seizures. By contrast, carbamazepine was devoid of any antiepieptogenic effects despite exhibiting marked anticonvulsant effects. Like valproate, phenobarbital exhibited both antiepileptogenic and anticonvulsant properties, but its antiepileptogenic properties were significantly less pronounced. The antiepileptogenic effects of valproate and phenobarbital strengthen the candidacy of these agents for the clinical studies needed to investigate pharmacological prevention of the development of epilepsy in high-risk groups.

Ganglioglioma: a clinical study with long-term follow-up

Gangliogliomas are uncommon tumors of mixed neoplastic glial and neuronal elements. Because of their low incidence, few large series exist that fully describe the clinical characteristics of patients afflicted with this tumor. We have reviewed the medical records of 20 patients at Duke University Medical Center with histologically proven gangliogliomas. These patients typically presented within the first three decades of life and their most common presenting symptom was seizures. Therapies included surgical resection, either partial or total, radiation therapy, and/or chemotherapy. Long-term follow-up was achieved by chart review and by telephone interview. Patients who underwent gross total resection alone seemed to fare the best when comparing all treatment groups, and we therefore recommend this as the main form of treatment.

Behavioral, biochemical, and cardiovascular responses to the benzodiazepine receptor antagonist flumazenil in panic disorder

To evaluate the possibility that abnormal regulation of benzodiazepine receptor (BZR) function may relate to the pathophysiology of anxiety disorders, two doses of the BZR antagonist flumazenil (Ro 15-1788) and placebo were administered to panic disorder patients in a double-blind, randomized, crossover design. All 11 patients received flumazenil (600 mg). Ten of the 11 also received flumazenil (200 mg), and 8 of the 11 were given matching placebo capsules orally on separate test days. Neither dose of flumazenil showed significant anxiolytic effects or significantly altered heart rate, blood pressure, or levels of plasma cortisol or 3-methoxy-4-hydroxyphenylglycol in comparison to placebo. On 200 mg days, anxiety ratings on a visual analog scale significantly increased compared to placebo at 30 min and then returned to baseline levels. Panic attacks occurred on placebo, 200 mg, and 600 mg days in 0/8, 4/10, and 0/11, respectively. Failure to observe anxiolytic effects suggests that flumazenil at these doses does not antagonize a tonic increased interaction of BZRs with an endogenous BZR inverse agonist in panic patients.

New approaches in the pharmacotherapy of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) may develop after exposure to severe stress, such as combat, accidents, assaults, and natural disasters. Pharmacotherapy can be a useful adjunct in the comprehensive treatment of these patients. The presence of comorbid conditions, including depression, panic disorder, substance abuse, and traumatic brain injury, should be carefully evaluated. Symptoms of PTSD that are associated with central nervous system hyperarousal or reexperiencing of the traumatic event appear to be the most responsive to pharmacotherapy. Social withdrawal and dulled responsiveness have not been shown to be alleviated through standard pharmacologic interventions. A therapeutic strategy is proposed that is based on the patient's symptoms and initial response to medication.

Pharmacologic management of aggression in the elderly

Issues related to the epidemiology, nosology, and differential diagnosis of organic aggressive disorders in the elderly are discussed. Rating and monitoring of aggressive events using the Overt Aggression Scale are reviewed. The management of acute aggression with antipsychotic agents and benzodiazepines is presented, as well as an approach for using beta-blockers, anticonvulsant agents, and serotonin-specific antidepressants and an antianxiety agent for the treatment of chronic aggression.

Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam

The Observer's Assessment of Alertness/Sedation (OAA/S) Scale was developed to measure the level of alertness in subjects who are sedated. This scale was tested in 18 subjects in a three-period crossover study to assess its reliability and its criterion, behavioral, and construct validity. After receiving either placebo or a titrated dose of midazolam to produce light or heavy sedation, each subject was administered two sedation scales (OAA/S Scale and a Visual Analogue Scale) and two performances tests (Digit Symbol Substitution Test and Serial Sevens Subtraction). Two raters individually evaluated the subject's level of alertness on each of the two sedation scales. The results obtained on the OAA/S Scale were reliable and valid as measured by high correlations between the two raters and high correlations between the OAA/S Scale and two of the three standard tests used in this study. The OAA/S Scale was sensitive to the level of midazolam administered; all pairwise comparisons were significant (p less than 0.05) for all three treatment levels at both test periods.

Psychopharmacology of depression in neurologic disorders

Depression occurs frequently in patients with neurologic disorders. Current research in traumatic brain injury, stroke, Parkinson's disease, multiple sclerosis, epilepsy, and brain tumors indicates that affective symptomatology can be a specific sequel of these illnesses that is related to the resultant impairment in brain functioning. Because of the cognitive and emotional deficits that neurologic disorders can cause, the clinician must be aware of the complicated presentation of depression in these patients. Psychopharmacologic treatments are safe and efficacious in the treatment of depression in patients with neurologic illness.

The safety of switching rapidly from tricyclic antidepressants to monoamine oxidase inhibitors

Monoamine oxidase inhibitors (MAOIs) are increasingly used for patients who do not respond to an initial trial of tricyclic antidepressants (TCAs). Although there are insufficient data documenting the optimal manner for switching a patient from a TCA to an MAOI, standard references advise a drug-free interval of at least 1 week. In clinical practice, however, such a delay may be difficult to observe. In order to explore the safety of a more rapid switch from TCA to MAOI therapy, we survey members of our department (Columbia University) as to their experience with different methods of switching patients from TCAs to MAOIs. Thirty-three respondents reported having switched an estimated 432 patients over the course of 3 years, with 178 patients switched within 4 days of discontinuing TCA therapy, including 63 who had the MAOI added while still being tapered from the TCA. More experienced psychiatrists tended to be less conservative, some using time intervals of 4 days or less. No adverse reactions were reported, including hypertensive and hyperpyrexic crises. This retrospective survey and an accompanying review of the literature suggest that the recommended drug-free interval of a week or more when switching patients from TCAs to MAOIs may be overly conservative.

The role of substantia nigra in the development of kindling: pharmacologic and lesion studies

The role of substantia nigra (SN) in the development of kindling was investigated. Microinjection of gamma-vinyl gamma-aminobutyric acid (GVG), a gamma-aminobutyric acid (GABA) transaminase inhibitor, into the SN bilaterally retarded kindling development by 77%. GVG injected dorsal to the SN did not alter the kindling rate. By contrast, lesions of the SN, whether by thermocoagulation or by microinjected neurotoxin, N-methyl-D,L-aspartate, facilitated kindling development by 27-44%. Thermocoagulative lesions dorsal to the SN did not affect the rate of kindling development. Thus these two manipulations, each presumed to suppress the activity of the SN, resulted in opposite effects on kindling development. We interpret the pharmacologic findings to indicate that the intact SN can powerfully facilitate kindling development. However, the SN is not vital for kindling development, since kindling can be established after destruction of a considerable portion of SN. Whether the increased rate of kindling development following SN lesions is due solely to the absence of SN remains unclear.

Sacrococcygeal rhizotomy for perineal pain

Chronic pain in the perineum is a difficult neurosurgical problem. This article evaluates the effectiveness of sacrococcygeal rhizotomy in 28 patients who had cancer-related pain or coccydynia, underwent rhizotomy, and were followed for an average of 3 years. Good pain relief was obtained in 53% (10 of 19 patients) with malignant pain, as opposed to 22% (2 of 9 patients) with nonmalignant pain. Sacral rhizotomy is a reasonable treatment for cancer-related perineal pain, but it is ineffective for coccydynia and other benign perineal pain problems.

Elevation of thioridazine plasma levels by propranolol

As part of a pilot study to assess the efficacy of propranolol in the treatment of aggression in psychiatric patients, drug interactions of propranolol with other agents were estimated by blood level monitoring. In the two patients taking a standard oral dose of thioridazine, the addition of propranolol caused a threefold and fivefold increase of plasma thioridazine levels, which placed them in a potentially toxic range. Although neither patient exhibited a toxic effect, these levels may be associated with an increased risk of thioridazine-induced irreversible pigmentary retinopathy, cardiac arrhythmias, and tardive dyskinesia. The authors suggest precautionary monitoring of thioridazine plasma and other relevant levels and clinical assessments when thioridazine and propranolol are used in combination.

Method of lesioning brainstem determines seizure probability

We examined 3 different methods of brainstem lesioning to assess their propensities to evoke seizures in the early postoperative period. Lesioning by electrolysis or microinjection of the neurotoxin, N-methyl-D,L-aspartate, caused seizures, but lesioning by thermocoagulation (radiofrequency current) did not. In paradigms in which postoperative lesion-induced seizures could confound interpretation of experimental results, the thermocoagulative method offers an important advantage.

The Overt Aggression Scale for the objective rating of verbal and physical aggression

The authors describe the design and reliability of a rating scale that measures aggressive behaviors in adults and children. On the Overt Aggression Scale (OAS), aggression is divided into four categories: verbal aggression, physical aggression against objects, physical aggression against self, and physical aggression against others. In addition, specific interventions related to each aggressive event can be recorded on the OAS. The clinical and research applications of this scale are discussed.

Unusual manifestations of gallstone migration into the gastrointestinal tract

Eighty-one cases of mechanical small bowel obstruction were seen at our hospital in the three year period 1978 to 1980. Four (5%) were due to gallstone ileus, three of them in women. All four patients were more than 75 years of age. Because most patients with biliary-enteric fistulas and gallstone ileus are elderly and in poor general condition, simple removal of the obstruction gallstone is usually adequate, but interval cholecystectomy is recommended in patients with a long life expectancy, because recurrence of calculi and symptoms increases with time.

Thyroid-stimulating hormone response to thyrotropin-releasing hormone in unipolar depression before and after clinical improvement

Fourteen patients with unipolar depression who had a blunted thyroid-stimulating hormone (TSH) response to infusion of 500 micrograms of thyrotropin-releasing hormone (TRH) and who showed marked clinical improvement after pharmacotherapy and/or electroconvulsive therapy had the TRH test repeated after improvement. The mean (+/- SD) maximal TSH response to TRH (delta TSH) increased significantly from 4.0 +/- 1.9 to 9.1 3.5 micro IU/ml. The number of patients with delta TSH less than 7.0 micro IU/ml increased significantly from 0 to 9 of 14 after improvement. Eleven of the patients were followed for 5 to 19 months, and none showed clear relapse. The results suggest that the blunted TSH response to TRH has features of both a state marker for active unipolar depression and a trait marker for vulnerability to this illness, and support the suggestion that the TRH test may be useful in diagnosis and treatment planning.

Pinocytosis in fibroblasts. Quantitative studies in vitro

Horseradish peroxidase (HRP) was used as a marker to determine the rate of ongoing pinocytosis in several fibroblast cell lines. The enzyme was interiorized in the fluid phase without evidence of adsorption to the cell surface. Cytochemical reaction product was not found on the cell surface and was visualized only within intracellular vesicles and granules. Uptake was directly proportional to the administered concentration of HRP and to the duration of exposure. The rate of HRP uptake was 0.0032-0.0035% of the administered load per 10(6) cells per hour for all cells studied with one exception: L cells, after reaching confluence, progressively increased their pinocytic activity two- to fourfold. After uptake of HRP, L cells inactivated HRP with a half-life of 6-8 h. Certain metabolic requirements of pinocytosis were then studied in detail in L cells. Raising the environmental temperature increased pinocytosis over a range of 2-38 degrees C. The Q(10) was 2.7 and the activation energy, 17.6 kcal/mol. Studies on the levels of cellular ATP in the presence of various metabolic inhibitors (fluoride, 2-desoxyglycose, azide, and cyanide) showed that L cells synthesized ATP by both glycolytic and respiratory pathways. A combination of a glycolytic and a respiratory inhibitor was needed to depress cellular ATP levels as well as pinocytic activity to 10-20% of control values, whereas drugs administered individually had only partial effects. In spite of the availability of an accurate quantitative assay for fluid and solute uptake, the function of pinocytosis in tissue culture cells remains unknown.