A cross-cultural study of the reliability and factorial dimensions of the Brief Psychiatric Rating Scale (BPRS).

The factor-structure and the reliability of the Brief Psychiatric Rating Scale (BPRS) was investigated in a group of short stay psychiatric patients in a Dutch university clinic. It was found that the BPRS has a good inter-rater reliability. With the exception of a new Disorientation subscale all original five subscales could be replicated when compared with an American study.

Cervical nodal metastases of unknown origin.

A study of 48 patients with metastatic carcinoma in the neck from an unknown primary site has revealed several facts. Among patients with squamous cell carcinoma, the three-year survival rate was 40%. Whether treated with surgery (radical neck dissection) or with radical irradiation alone, the response of these tumors was similar in smaller N1 nodes; when treated with a combined therapeutic approach, they responded well in larger (N2 and N3) cervical nodes. Whether or not the primary tumor was fond did not affect survival rates; the stage of the presenting nodal metastases did not appear to correlate with survival. A large group of patients with adenocarcinoma metastatic to cervical lymph nodes all died of the disease within two years. All appeared with metastases in the supraclavicular fossa; no modality of treatment to the neck, whether by surgery or irradiation, was effective.

Five-year multicenter retrospective review of cyclobenzaprine toxicity.

Cyclobenzaprine (CBP) has a cyclic structure similar to amitriptyline. In overdose, CBP has been suggested to produce the cardiovascular and neurologic toxicity found with the cyclic antidepressants. To examine this possibility, a retrospective chart review of all cases of CBP exposure reported to five regional poison centers was performed for the years 1989-93. There were a total of 750 charts identified for CBP exposure, of which 523 had data sufficient for evaluation. There were 121 polydrug ingestions leaving 402 pure CBP ingestions. Ages ranged from 7 mo to 77 yrs, with a mean of 20 yrs; 26% were 6 yrs or less. Females comprised 63% of the patient group. No deaths occurred. Dysrhythmias beyond sinus tachycardia were infrequent, and none were life-threatening. No seizures occurred. Common effects were lethargy, sinus tachycardia, and agitation, and both hypertension and hypotension were seen. All symptomatic cases with a known time of ingestion were symptomatic within 4 h of ingestion. Doses ingested ranged from 5-1000 mg, with a mean of 133 mg. Asymptomatic and symptomatic patients had a mean dose ingested of 45 mg and 183 mg, respectively. Treatment was primarily gastrointestinal (GI) decontamination and supportive care. Other therapies required were mechanical ventilation, dopamine, fluid bolus, sedation, and foley catheter. Symptoms requiring treatment beyond GI decontamination did not occur with ingestions less than 100 mg. In conclusion, cyclobenzaprine does not appear to produce the life-threatening cardiovascular or neurologic effects of the cyclic antidepressants in doses less than 1 g. Lethargy and anticholinergic effects are prominent, though serious toxicity is infrequent.

Total laparoscopic hysterectomy using the harmonic scalpel.

Total laparoscopic hysterectomy (TLH) is the complete hysterectomy including transection of the uterine vessels and opening/closure of the vaginal vault performed laparoscopically. This procedure can be performed as an alternative to total abdominal hysterectomy in many cases. We previously found use of the harmonic scalpel to be extremely helpful in performing laparoscopically assisted vaginal hysterectomies. In this series, the harmonic scalpel was used to facilitate performing TLH. Our experience has shown this can be performed without major complications in a cost-effective manner.

[Psychogeriatrics in Great Britain--report of the Nottingham course 1984]. / Psychogeriatrie in Groot-Brittannië--verslag van de Nottingham-cursus 1984.

The British Council's Course 'Psychogeriatrics' at the University of Nottingham reflects the state and development of the internationally acknowledged psychiatry of old age in Britain. This article describes the contents of the course in terms of epidemiology, organization, diagnosis and treatment, with special attention to aspects of education and research. It concludes with a remark on the identity of the subject, stating that psycho-geriatrics has its emphasis in training and research rather than being a medical subspecialty.

[Comparison between 2 behavior observation scales in psychogeriatrics. A closer look at the NOSIE and the BOP]. / Een vergelijking tussen twee gedragsobservatieschalen in de psychogeriatrie. De NOSIE en de BOP nader onderzocht.

The relation between the NOSIE (Nurses' Observation Scale for Inpatient Evaluation) and the BOP (Dutch version of the Stockton Geriatric Rating Scale) was studied in a psycho-geriatric sample. The results supported the hypothesis of a trans-cultural difference in the use of the NOSIE. Dutch nurses subsume personal neatness under social competence. Anglo-Saxons do not. The factor solution of the NOSIE, with the exception of the depression factor, was comparable with earlier Dutch research, and was interpreted as support for the notion, that the NOSIE is a reliable observation scale. The correlation between factor scales of the NOSIE and the BOP were significant, but of moderate range. This was taken to mean that there is limited convergent validity between the NOSIE and the BOP. A high correlation was found between the infirmity scale and other subscales of the BOP. The BOP as well as the NOSIE were able to purposefully distinguish diagnostic groups when an external criterium or mixed criteria were used. It was concluded that both the BOP and the NOSIE may supplement each other in psycho-geriatric research practice.

[Application of the BOP (an evaluation scale for older patients) in a psychiatric hospital. A clinical study]. / Het gebruik van de BOP in een psychiatrische kliniek. Een praktijkonderzoek.

In this study we examined the relationship between BOP rating scores and psychiatric diagnoses at discharge of 74 psychogeriatric patients admitted to the AZUA psychiatric clinic. The BOP is the Dutch rating scale modelled after the Stockton Geriatric Rating Scale. The BOP was administered two weeks after admittance, and a second time four weeks later. These results were compared with results from an earlier study. The usefulness of the BOP as viewed by the treatment and nursing staff was evaluated. Treatment team evaluation of the BOP revealed some shortcomings. Members found the information too global und redundant. Reflecting their training and own point of view, the nursing staff too gave critical assessments of the BOP. Analysis of the first BOP rating scores showed a positive correlation between three BOP subscale scores and the discharge diagnosis of dementia. Closer inspection revealed that this relation was limited to male patients suggesting that both the patient sex and the nature of the dementia may be factors influencing BOP rating scores.

Free radical-induced carbonyl content in protein of estrogen-treated hamsters assayed by sodium boro[3H]hydride reduction.

Oxidative damage to proteins is known to occur via conversion of side chain amino groups to corresponding carbonyl derivatives. Such damage to enzymes and purified proteins has been quantified previously by reduction with sodium boro[3H]hydride and subsequent measurement of the incorporation of 3H into amino acid fractions. In this study, the NaB3H4 reduction assay was modified to permit the quantitation of free radical-mediated oxidative damage to proteins obtained from animals. Modifications included additional extractions of protein isolates with organic solvents to remove lipids and with nitric acid to remove metal ions. The modified assay has first been validated in vitro by measuring changes in levels of oxidative damage to bovine serum albumin exposed to xanthine plus xanthine oxidase (2-fold increase), to hydrogen peroxide and iron(II) sulfate (5-fold increase), or to gamma radiation (30-fold increase over controls, respectively). gamma radiation of isolated hamster kidney protein also raised the carbonyl content in a dose-dependent manner. The modified assay has then been validated in vivo by measuring the changes in oxidative damage to lung tissue in animals exposed to approximately 85% oxygen (2-fold increase) or to different doses of paraquat (5-fold increase with the high dose over controls, respectively). The assay was then used to examine free radical-mediated oxidation introduced by acute or chronic treatment of hamsters with estrogens, since both synthetic and natural estrogens induce kidney tumors in this species. Priming of hamsters for 3 days with 20 mg/kg/day diethylstilbestrol and treatment with 100 mg/kg of this drug on the 4th day resulted in a 160% increase in free radical modification of renal proteins. Oxidative damage to kidney proteins was also assayed in hamsters treated with estradiol implants for up to 7 months, a regimen known to induce kidney tumors. Significant increases in covalent oxidative modification to renal proteins over values in age-matched controls were detected after 1, 2, and 7 months of continuous estradiol exposure. It is concluded that the modification of the NaB3H4 reduction assay is a useful postlabeling method for monitoring free radical action in vivo. Furthermore, it is postulated that free radical damage in estrogen-treated hamster kidney plays a role in estrogen-induced carcinogenesis.

Possible mechanism of induction of benign prostatic hyperplasia by estradiol and dihydrotestosterone in dogs.

A mechanism of induction of canine benign prostatic hyperplasia (BPH) by androgen-stimulated growth of prostatic cells exposed to estrogen-induced toxicity. Estrogen is thought to be activated by redox cycling of catechol metabolites, a mechanism of generation of active radicals. Mongrel dogs, 4 animals/group, were sham-operated (controls) or were treated for 60 days with implants of 5 alpha-dihydrotestosterone and/or estradiol-17 beta. The activities of drug and hormone metabolizing enzymes (aryl hydrocarbon hydroxylase, 7-ethoxycoumarin O-deethylase, and estradiol-17 beta-2- and -4-hydroxylase) in prostate were significantly elevated by chronic treatment with either estradiol-17 beta or 5 alpha-dihydrotestosterone plus estradiol-17 beta, but not in kidney or liver which are not targets of hormone-induced hyperplasia. Activities of the detoxifying enzymes catalase and glutathione peroxidase I in prostate were increased by estradiol-17 beta treatment, whereas in kidney or liver they were not affected or changed to a lesser degree than observed in prostate. Free radial-induced damage (carbonyl content) of proteins was observed in prostate of dogs treated with either estradiol-17 beta or 5 alpha-dihydrotestosterone plus estradiol-17 beta and in liver protein by treatment with either 5 alpha-dihydrotestosterone or 5 alpha-dihydrotestosterone plus estradiol-17 beta. It was concluded that the patterns of estradiol-17 beta- or 5 alpha-dihydrotestosterone plus estradiol-17 beta-induced increases in activities of catechol estrogen synthase and of other drug metabolizing enzymes were consistent with the postulated free radical generation by redox cycling of catechol estrogen specifically in the prostate. The increases in activities of detoxifying enzymes may represent an (albeit insufficient) response to prostatic free radical damage to protein in prostate is consistent with a postulated induction of BPH via injury by estrogen metabolites followed by 5 alpha-dihydrotestosterone-stimulated growth of altered prostatic cells.

Automatic dishwashing detergents: their pH, ingredients, and a retrospective look.

Ingestion of automatic dishwasher detergents is an increasing problem in households with small children. Historically these ingestions have been handled as alkaline corrosive ingestions. However, after many formulation changes since the late 1950's, a re-evaluation of treatment modality is in order. This report examines the pH of varying concentrations of many of the available automatic dishwashing detergents, their specific ingredients, and include a retrospective study of childhood ingestion of these products from 1978-1984.

Urine fluorescence using a Wood's lamp to detect the antifreeze additive sodium fluorescein: a qualitative adjunctive test in suspected ethylene glycol ingestions.

Antifreeze ingestions require rapid and accurate differential diagnosis to prevent fatal outcomes. Sodium fluorescein is added to some commercial antifreeze preparations (ethylene glycol) to a final concentration of approximately 20 micrograms/mL as a colorant to aid in detection of automobile cooling-system leaks. For an adult human being, a potentially toxic volume of antifreeze is 30 mL, which contains 0.4 to 0.6 mg sodium fluorescein. Six male volunteers were given a 0.6-mg oral bolus of sodium fluorescein on an empty stomach. Urine was collected at two-hour intervals. Using a Wood's lamp, visually detectable fluorescence was seen with 100% reliability for two hours and 60% reliability for four hours. A second group of male volunteers was given the same dose of sodium fluorescein, and fluorescence was measured with a fluorometer during a six-hour period. Detectable fluorescence was present in all samples except the zero time point, including those with no fluorescence present by visual examination. We conclude that exposing urine to a Wood's lamp may be a useful adjunctive diagnostic test for early evaluation of patients with suspected antifreeze ingestion while awaiting definitive quantitative analysis of serum ethylene glycol concentration. A prospective clinical trial is needed to evaluate the frequency of false-positives and false-negatives.

The principle of separate responsibility in clinical psychiatric practice. 6 years' experience.

An experiment lasting 6 years with an organizational principle called 'separate responsibility' is described. Its aim was to promote open two-way communication in an acute psychiatric admission clinic, by dividing power, i.e. responsibility for individual patients and patients as a group, over two multidisciplinary treatment teams. Multidisciplinarity, however, turned out to be impossible to maintain for different reasons. Instead, a splitting occurred of medical and nursing disciplines through identification of the former with individual treatment and of the latter with the patient groups. An unproductive loss of common treatment goals was the result leading to a near closing down of the clinic. Putting medical and nursing personnel into one team, responsible for the entire treatment of the unit, restored productivity and improved treatment and the working climate.

A cross-cultural study of the reliability and factorial dimensions of the Nurses' Observation Scale for Inpatient Evaluation (NOSIE).

Investigated the reliability and factor structure of the Nurses' Observation Scale for Inpatient Evaluation (NOSIE) in a group of short-stay psychiatric patients (N = 247) of a Dutch psychiatric university clinic. It was found that the NOSIE has good interrater reliability. With the exception of the Social Competence and Personal Neatness subscales five of the original seven scales could be replicated when compared with American and British studies.

A noninvasive technique for monitoring changes in canine prostatic size in vivo.

We describe a procedure for monitoring changes in canine prostatic size. Metal beads were sutured to the surface of the prostate and the interbead distances were derived from two X-rays taken at right angles. Prostatic hyperplasia was induced by castration and injection of 5 alpha-androstane-3 alpha, 17 beta-diol and 17 beta-estradiol. Prostatic regression was caused by castration without further treatment. Although growth of the prostate was nonuniform, changes in prostatic volume were shown to be related to the third power of the distance between appropriate beads. This monitoring technique can be repeated every 2nd day if necessary, and thus has an advantage over procedures that require repeated laparotomies. Significant increases in prostatic volume could be detected within 5 days after steroid injection.

Induction of benign prostatic hyperplasia in intact dogs by near-physiological levels of 5 alpha-dihydrotestosterone and 17 beta-estradiol.

Benign prostatic hyperplasia was induced in mongrel dogs treated for 60 days with one silastic implant containing 17 beta-estradiol and four containing 5 alpha-dihydrotestosterone. The condition was characterized by (1) a marked increase of the stromal elements, particularly the stromal septa between the individual glands, (2) a slight increase in prostatic volume, and (3) a morphology that resembled spontaneous complex benign prostatic hyperplasia in the dog. Other groups of animals that remained untreated or received only 17 beta-estradiol or only 5 alpha-dihydrotestosterone did not develop this condition. Prostate volumes decreased by 14% in the estrogen-treated dogs, whereas they increased in the androgen-treated animals by 6% compared to pretreatment prostate volumes. The morphology of the epithelium of the prostates of androgen-treated animals was not different from that of controls despite the increase in prostate volume. The serum 17 beta-estradiol and 5 alpha-dihydrotestosterone concentrations were increased from 25 +/- 2 (mean +/- SEM) and 256 +/- 42 pg/mL, respectively, in control dogs to 52 +/- 37 and 562 +/- 37 pg/mL, respectively, in the dogs treated with the hormone combination. Thus, hormone concentrations were two- to three-fold higher than control values, and the ratio of estradiol-17 beta to 5 alpha-dihydrotestosterone was increased by up to 19%. These data demonstrate that treatment of dogs with low levels of estrogen and androgen may be an excellent model for the study of spontaneous complex benign prostatic hyperplasia in aging men.

Multi-center retrospective evaluation of oral benzocaine exposure in children.

On rare occasions benzocaine has produced methemoglobinemia from oral, rectal and dermal exposures. There is disagreement whether this is an idiosyncratic event or a dose-related event. To gain a better perspective on this problem we retrospectively reviewed cases at 4 large regional poison centers of children <18-y of age from 1993-1996. One hundred and eighty-eight benzocaine exposures were reported. Mean and median ingested dosage were 86.8 (+/- 89.5) mg/kg and 50 mg/kg, respectively. Fifty-eight patients (30%) were managed in the emergency department; 8 patients had methemoglobin levels determined. One child had a methemoglobin level of 19%; all others were <1%. One hundred and seventy-three patients (92%) remained asymptomatic. Other symptoms were minor: oral numbness (8), vomiting (3), and 1 each of oral irritation, dizziness and nausea. In this series of accidental ingestions of benzocaine-containing products cyanosis was rare and apparently not dose related. These cases may be safely managed at home with telephone follow up for at least 2 h. If there is evidence of cyanosis, dusky pallor, shortness of breath, or change in mental status direct medical evaluation should be recommended.

Multicenter case series of valproic acid ingestion: serum concentrations and toxicity.

BACKGROUND: Valproic acid exposures reported to poison centers have increased more than 4-fold over the last 5 years. There are no large case series published on valproic acid ingestion. METHODS: A prospective multicenter case series of all patients reporting an ingestion of valproic acid. Data collected included: age, gender, dose ingested, concomitant medications, symptoms and vital signs, laboratory values, length of hospital stay, and medical outcome. Entrance into the study required a serum valproic acid concentration above the therapeutic threshold of 100 microg/mL. Statistical analysis was by Fisher's exact test. RESULTS: A total of 335 patients were reported to participating centers of which 186 (55%) had serum valproic acid concentrations greater than 100 microg/mL. Of the 186 cases, 53 were multiple drug exposures leaving 133 cases of sole valproic acid ingestion for evaluation. Age ranged from 2 to 66 years with a mean of 30.1 years +/- 12. Peak serum valproic acid concentrations ranged from 110 microg/mL to 1840 microg/mL with a mean of 378.3 microg/mL +/- 310.2 microg/mL. Time from postingestion to the peak measured valproic acid concentration ranged from 1 to 18 hours, with a mean of 7.4 hours +/- 3.9. Symptoms included lethargy (n = 94), coma (n = 19), tachycardia (n = 24), aspiration (n = 8), metabolic acidosis (n = 8), and hypotension (n = 4). A peak concentration of > 450 microg/mL was more likely to be associated with a moderate or major adverse outcome (p < 0.005). A peak concentration > 850 microg/mL was more likely to be associated with coma (p < 0.005) and acidosis (p < 0.005). Eleven patients experienced transient thrombocytopenia (platelets < 150,000) and all had peak valproic acid concentrations >450 microg/mL. Four patients experienced transient leukopenia (WBC < 3,500). The mean hospital stay for all patients was 42 +/- 33.1 hours. A hospital stay > 48 hours was more likely to be associated with a peak valproic acid concentration > 450 microg/mL (p < 0.05). There were 2 fatalities. CONCLUSIONS: In this case series, patients with peak valproic acid concentrations above 450 microg/mL were more likely to develop significant clinical effects and have longer hospital stays. A peak valproic acid concentration above 850 microg/mL was more likely to be associated with coma, respiratory depression, aspiration, or metabolic acidosis.

Multicenter case series of pediatric metformin ingestion.

OBJECTIVE: There are no large studies, case series, or case reports of metformin ingestion in children. This study summarizes the clinical course and outcomes of metformin ingestion in children reported to the American Association of Poison Control Centers-certified regional poison centers. METHODS: This was a case series of all metformin ingestions in patients <18 years of age reported to eight regional poison centers. Data collection included age, gender, dose ingested, co-ingestants, symptoms, vital signs, laboratory values, length of hospital stay, and medical outcome. Entrance into the study required at least 24 hours of follow-up. RESULTS: Fifty-five cases were collected. Ages ranged from 15 months to 17 years, with a mean (+/- SD) of 42+/-4.4 years. The dose ingested, by history, ranged from 250 mg to 16.5 g, with a mean and median of 1710+/-3391 and 500 mg, respectively. Forty-one children (76%) ingested a maximum of two tablets (< or =1700 mg). In the children younger than six years, dosage ranged from 9 to 196 mg/kg, with a mean and median of 60+/-41.1 and 40 mg/kg, respectively. Thirty-seven children were evaluated in a healthcare facility. Clinical effects were limited to nausea (2), diarrhea (2), and dizziness (1). None of the 38 children who had serial glucose measurements experienced hypoglycemia. Arterial blood gas and electrolyte measurements were performed in three and 19 children, respectively. No evidence of acidosis was demonstrated. Two children had lactate concentrations measured and were determined to be in the normal range. Twenty-nine patients received activated charcoal. Five patients received parenteral glucose and one adolescent with a history of diabetes received insulin for hyperglycemia. CONCLUSIONS: Unintentional ingestion of < or =1700 mg of metformin in the healthy pediatric population does not appear to pose a significant health risk of hypoglycemia or detrimental outcome. In the 21 children who were tested for either blood glucose, electrolyte, or lactate concentrations, no evidence of lactic acidosis was seen.