Traumatic central cord syndrome: neurological and functional outcome at 3 years.

STUDY DESIGN: Retrospective cohort analysis with prospective follow-up. OBJECTIVES: To evaluate neurological and functional recovery following central cord syndrome. SETTING: Northern Ireland, population 1.8 million. METHODS: Twenty-seven cords were identified in 1 year. Five managed conservatively and 22 with surgery. American Spinal Injury Association (ASIA) motor scores (AMS) were calculated to assess neurological recovery. Rotterdam scores assessed functional independence at 3 years. RESULTS: Average age was 62 years. Mechanism of injury was a fall with neck hyperextension in 81% patients. Average AMS in surgical patients improved from injury, preoperatively, postoperatively, 6 months and 3 years from 51, 81, 83, 90 to 96, respectively. Conservative patients improved from time of injury to day 10 from 57 to 86 and then fell to 84 at 6 months. By 3 years, this had recovered to 91. There was no statistical significant difference in AMS (P=0.15)/change in AMS (ΔAMS) (P=0.92) or percentage of motor deficit resolution (P=0.23) between groups at 3 years. Two patients underwent surgery within 48 h and achieved full motor recovery by 3 years, but this was not significant (P=0.2). ASIA score improvement had a positive correlation with age at injury. Patients treated with surgery had better Rotterdam scores at 3 years than those managed conservatively (P=0.05). CONCLUSIONS: This study confirms the natural history of central cord syndrome. Although it demonstrates equivocal neurological recovery for both groups, patients treated with surgery regained a greater degree of functional independence.

Evaluation of the diagnostic accuracy of four-view radiography and conventional computed tomography analysing sacral and pelvic fractures in dogs.

OBJECTIVE: The purpose of our study was (1) to determine whether four-view radiography of the pelvis is as reliable and accurate as computed tomography (CT) in diagnosing sacral and pelvic fractures, in addition to coxofemoral and sacroiliac joint subluxation or luxation, and (2) to evaluate the effect of the amount of training in reading diagnostic imaging studies on the accuracy of diagnosing sacral and pelvic fractures in dogs. METHODS: Sacral and pelvic fractures were created in 11 canine cadavers using a lateral impactor. In all cadavers, frog-legged ventro-dorsal, lateral, right and left ventro-45°-medial to dorsolateral oblique frog leg ("rollover 45-degree view") radiographs and a CT of the pelvis were obtained. Two radiologists, two surgeons and two veterinary students classified fractures using a confidence scale and noted the duration of evaluation for each imaging modality and case. The imaging results were compared to gross dissection. RESULTS: All evaluators required significantly more time to analyse CT images compared to radiographic images. Sacral and pelvic fractures, specifically those of the sacral body, ischiatic table, and the pubic bone, were more accurately diagnosed using CT compared to radiography. Fractures of the acetabulum and iliac body were diagnosed with similar accuracy (at least 86%) using either modality. CLINICAL SIGNIFICANCE: Computed tomography is a better method for detecting canine sacral and some pelvic fractures compared to radiography. Computed tomography provided an accuracy of close to 100% in persons trained in evaluating CT images.

Augmentation of diaphyseal fractures of the radius and ulna in toy breed dogs using a free autogenous omental graft and bone plating.

OBJECTIVES: Evaluation of the short-term outcome, duration of bone healing, and complications following bone plate fixation in dogs weighing ≤6 kg, with and without the use of a free autogenous greater omental graft (OG). MATERIALS AND METHODS: A retrospective clinical study reviewed the medical records of 25 dogs of body weight <6 kg with mid to distal diaphyseal fractures of the radius and ulna (29 fractures) treated with open reduction bone plate fixation. Thirteen out of 29 fractures were implanted with an additional 2-3 cm³ OG lateral, cranial, and medial to the fracture site, adjacent to the bone plate. RESULTS: Median time to radiographic healing in OG fractures (n = 11) was 70 days (range 28-98) compared to 106 days (range: 56-144) in non-OG grafted fractures (n = 14). The OG dogs had no major complications; minor complications included oedema, erythema, and mild osteopenia. Six of the eight non-OG dogs for which follow-up could be obtained developed osteopenia necessitating implant removal, four of which re-fractured the radius one to five months after implant removal, with one dog re-fracturing the limb a second time and resulting in amputation. Telephone follow-up of owners of OG dogs (n = 11) three to 15 months (median 10) post-surgery did not identify any signs of lameness or other complications. Owners of the non-OG dogs (n = 8) reported that there were not any signs of lameness six to 48 months (median 36) post-surgery. CLINICAL RELEVANCE: Free autogenous omental grafting of diaphyseal fractures of the radius and ulna was associated with radial and ulnar healing with minimal complications in dogs weighing less than 6 kg.

Use of computed tomography to compare two femoral head and neck excision ostectomy techniques as performed by two novice veterinarians.

OBJECTIVES: To compare the results of femoral head and neck excision (FHNE) ostectomy performed by two novice veterinarians using an osteotome and mallet or microsagittal saw. METHODS: In this ex vivo cadaveric study, hindlimbs of eight canine cadavers were randomized to FHNE with osteotome or micro sagittal saw as performed by two recently graduated veterinarians. The hindimbs were imaged by computed tomography (CT) before and after the osteotomy. Post FHNE CT images were evaluated by a board certified radiologist blinded to the ostectomy technique for assessment of the number of bone fragments, fissures, smoothness of osteotomy margination, and volume of residual femoral neck. RESULTS: Femoral head and neck excision performed with the osteotome produced more peri-ostectomy bone fragments, cortical fissures, irregular margins, and residual femoral neck volume, compared with osteotomy using a saw. CLINICAL RELEVANCE: Compared to FHNE performed with a sagittal saw, osteotome FHNE resulted in a greater bone trauma and residual neck bone volume, which would require post-ostectomy modification in a clinical setting.

Sertraline in the treatment of depression associated with gonadotropin-releasing hormone agonist therapy.

BACKGROUND: Endometriosis is thought to affect 5-10% of reproductive age women in the general population and is commonly treated with gonadotropin-releasing hormone (GnRH) agonists. Recent studies suggest depressive symptoms are associated with women treated with GnRH agonist for endometriosis. METHODS: A retrospective pilot study of 42 female patients, 22 in the treatment group (sertraline) and 20 in the control group (no sertraline), was conducted. All subjects had laproscopically diagnosed endometriosis and were treated with 24 weeks of GnRH agonist therapy. Assessment instruments included the Hamilton Depression Rating Scale and the Menopausal Symptom Index. RESULTS: The results indicate that patients receiving concomitant sertraline reported significantly less depressive symptoms, but did not differ significantly in physical symptoms than the group receiving a GnRH agonist alone. CONCLUSIONS: Antidepressants, such as sertraline, appear to be significantly helpful in the treatment of mood symptoms during the course of GnRH agonist therapy.

Adverse cutaneous reactions to antidepressants.

The authors review the literature on adverse cutaneous reactions to antidepressant medications. The prevalence of rashes ranges from approximately 2% to 4% but is higher for certain antidepressants such as maprotiline and carbamazepine. Antidepressant drug reactions result in a variety of cutaneous morphologic patterns, but the majority of eruptions are exanthematous. The patterns of these reactions are similar whether the pathogenesis is mediated by immunologic or nonimmunologic mechanisms. The management of patients with adverse cutaneous reactions to antidepressants is discussed, and various recommendations are given.

Effects of pH on responses to adenosine, CGS 21680, carbachol and nitroprusside in the isolated perfused superior mesenteric arterial bed of the rat.

1. The receptors mediating the vasodilator responses to adenosine in the isolated mesenteric arterial bed of the rat were identified by use of selective agonists and antagonists and the involvement of the endothelium was examined. 2. Adenosine-mediated dilatation of the mesentery was potentiated by the nitric oxide synthase inhibitor, NG-nitro-L-arginine methyl ester (L-NAME, 100 microM), but in contrast, removal of the endothelium substantially reduced the responses to adenosine. 3. The order of potency of adenosine receptor agonists was: 5'-N-ethylcarboxamidoadenosine (NECA) > 2-p-(-2-carboxyethyl)phenethylamino-5'-N-ethylcarboxamidoadenosine (CGS 21680) > 2-chloro-N6-cyclopentyl-adenosine (CCPA) > or = adenosine, suggesting the presence of A2A receptors. 4. Adenosine-mediated dilatation was inhibited by the non-selective adenosine receptor antagonist, 8-phenyltheophylline (3 microM) and by the A2A receptor antagonist 8-(3-chlorostyryl)caffeine (500 nM), but was unaffected by the A1 receptor antagonist, 1,3-dipropyl-8-cyclopentylxanthine (DPCPX; 10 nM). 5. Reducing the pH of the perfusate to 6.8 potentiated the actions of both CGS 21680 and adenosine, but the vasodilator effects of carbachol were the same at both pH values. The adenosine response at the lower pH as at pH 7.4, was unaffected by DPCPX. The actions of the nitrovasodilator, sodium nitroprusside, were also potentiated at pH 6.8 relative to those at the higher pH value but smaller responses were obtained at the lower pH value with forskolin, a stimulator of adenylyl cyclase, than at pH 7.4. 6. It is concluded that the adenosine receptor mediating dilatation of the rat mesenteric arterial bed is of the A2A subtype, that the response, under the conditions used, is apparently partly dependent on the endothelium (but not due to the release of nitric oxide), and that the response to activation of this receptor is potentiated by a reduction in pH which is similar to that seen in ischaemic conditions.

Lysis of a left ventricular thrombus with recombinant tissue plasminogen activator.

A 23-year-old woman with peripartum cardiomyopathy presented with a 2.1 x 2.5-cm pedunculated, mobile, left ventricular thrombus and evidence of systemic embolization. Due to the patient's poor left ventricular function, thrombectomy was not a viable option. Treatment with high-dose IV heparin was initially utilized but was unsuccessful as the thrombus appeared to enlarge on echocardiography. An accelerated weight-adjusted dose of recombinant tissue plasminogen activator (rt-PA) successfully lysed the thrombus without evidence of embolization. Although rt-PA has been used for primary lysis of high-risk ventricular thrombi, this is the first documentation of successful lysis of a left ventricular thrombus in a patient with peripartum cardiomyopathy.

Depressive mood symptoms associated with ovarian suppression.

OBJECTIVE: To determine if sertraline is helpful in the management of depressive symptoms associated with ovarian suppression during GnRH agonist therapy as compared with a placebo-controlled group. DESIGN: Double-blind placebo-controlled prospective study design. SETTING: An obstetrics/gynecological office specializing in infertility in an academic environment. PATIENT(S): Premenstrual women with laparoscopically diagnosed endometriosis who required GnRH agonist therapy for treatment and did not have significant depressive or premenstrual mood symptoms at baseline. INTERVENTION(S): Participants were randomly assigned to either the sertraline treatment group or to the placebo group for the 3-month duration of the GnRH agonist therapy. MAIN OUTCOME MEASURE(S): The 21-item Hamilton Rating Scale for Depression (HRSD), which is an instrument designed to assess depressive symptomatology. RESULT(S): A Hotellings T(2) test for repeated measure analysis indicated a statistically significant (P<.05) between-group difference across time for the HRSD (T(2) = 13.3; F[3, 28] = 4.1; P=.02) with the sertraline treatment group manifesting significantly fewer depressive symptoms than the control group. CONCLUSION(S): The results indicate that sertraline is an effective option in the management of depressive mood symptoms associated with ovarian suppression during GnRH agonist therapy.

Pharmacologic treatment of severe skin-picking behaviors in Prader-Willi syndrome. Two case reports.

BACKGROUND: Prader-Willi syndrome (PWS) is characterized by hypotonia at birth, hypogonadism, early childhood obesity, and mental deficiency. Other behavioral symptoms that become prominent during adolescence and adulthood include temper outbursts, stealing and hoarding food, and skin picking. The self-excoriating skin picking behavior observed in individuals with PWS is quite common and can lead to persistent sores and infections, even requiring hospitalization. OBSERVATION: Two patients with PWS who displayed repetitive, self-mutilatory behavior of skin picking are described. They were both treated successfully with different doses of fluoxetine, a selective serotonin reuptake inhibitor. CONCLUSIONS: The skin-picking behavior in patients with PWS may be a variant of the spectrum of obsessive-compulsive disorders. Obsessive-compulsive disorders have been successfully treated with serotonin reuptake inhibitors such as fluoxetine. Thus, fluoxetine may be considered an option in the management of skin-picking behavior in patients with PWS.

Obsessive-compulsive disorder.

The prevalence of OCD in a dermatologic practice may be much higher than in the general population. OCDs can be debilitating in one's interpersonal, social, and occupational functioning. The obsessions and compulsions typically begin fairly early in life and may consume prolonged lengths of the patient's time to complete daily rituals of washing, checking, touching, arranging, hoarding, or ruminating. Evidence is mounting for support of a neurobiologic basis in the etiology of OCD. In terms of treatment, the psychopharmacologic agents (clomipramine, fluoxetine, fluvoxamine, sertraline, paroxetine) and behavior therapy alone or in combination with SRIs help a significant majority of patients suffering from this disorder. The OCD spectrum of disorders is varied. Patients presenting to the dermatologist will exhibit an interesting array of symptoms, including those who compulsively hand wash, pick at nails or skin, pull body hair, or display other SIB. Increased awareness of these disorders will enable the dermatologist to identify and treat patients with OCD appropriately.

A controlled study of Trancopal in the treatment of sleep disturbances due to anxiety.

Sixty-eight patients presenting with sleep disturbances due to mild neurotic anxiety were treated for two weeks with a single night-time dose of 400 mg trancopal or matching placebo under double-blind conditions. Patients kept a daily record of the quality of their sleep and the observer carried out a weekly rating of anxiety using a modified Hamilton scale. By Day 7 patients receiving Trancopal had a significantly better rating for sleep and mean Hamilton scores for day-time anxiety than the placebo group. Side-effects were minimal. It was concluded that for patients with sleep disturbances due to neurotic anxiety Trancopal is a well tolerated and effective alternative to the hypnotics.

Training psychiatric residents for Part II of the American Board of Psychiatry and Neurology Examination.

Of the physicians who took the American Board of Psychiatry and Neurology (ABPN) Examination, Part II, in 1995, 41% failed. The Accreditation Council for Graduate Medical Education (ACGME) requires that residency psychiatry programs conduct an organized evaluation of residents' clinical skills at least twice during the 4 years of training. At the University of Oklahoma Health Science Center-Tulsa, the residents attend formal didactic instruction on conducting a psychiatric interview. Having gained this didactic foundation, they then participate in actual patient interviews. First- and 3rd-year residents are mock examiners, paired with an experienced board-certified psychiatrist. Second- and 4th-year residents examine an actual patient. A survey evaluating this curriculum was rated as very good to excellent by the participants.

Effectiveness of a Mobile Outreach and Crisis Services unit in reducing psychiatric symptoms in a population of homeless persons with severe mental illness.

The purpose of this study was to use a time-lag design to evaluate the effectiveness of a Mobile Outreach and Crisis Services unit in remitting psychiatric symptomatology, improving global functioning, and decreasing homelessness in a population of homeless, severely mentally ill residing in a mid-sized urban center. Using a time-lag study design, two groups of subjects--25 individuals before receiving services (control group) and 25 individuals after receiving services (experimental group)--were contrasted across outcome measures. The results indicate that a MOCS unit utilizing a Program for Assertive Community Treatment mode was effective in significantly decreasing psychiatric symptomatology, reducing homelessness, and increasing global functioning. If carefully implemented and interpreted, a time-lag design may be a means of providing valuable feedback and information in a timely manner.

Diabetes mellitus and major depression: considerations for treatment of Native Americans.

Non-insulin dependent diabetes mellitus (NIDDM) extracts a heavy toll on the Native American community in the United States. Evidence indicates that patients with NIDDM are three times more likely to have a co-existing diagnosis of depression. Untreated major depression unfavorably impacts the complication rates of NIDDM. Thus, Native Americans who are at increased risk for NIDDM are likely to be at increased risk for major depression. Physicians in Oklahoma should be aware of important treatment issues when selecting an antidepressant medication to treat major depression in Native Americans with NIDDM. Treatment options for major depression in the context of diabetes are discussed. Evidence currently indicates that the serotonin reuptake inhibitors (SSRIs) have significant advantages and a more favorable side effect profile for the treatment of depression in patients with diabetes mellitus.

Growth factor treated tensioned synoviocyte neotissues: towards meniscal bioscaffold tissue engineering.

Meniscal injury is a common cause of osteoarthritis, pain, and disability in dogs and humans, but tissue-engineered bioscaffolds could be a treatment option for meniscal deficiency. The objective of this study was to compare meniscus-like matrix histology, composition, and biomechanical properties of autologous tensioned synoviocyte neotissues (TSN) treated with fetal bovine serum (TSNfbs) or three chondrogenic growth factors (TSNgf). Fourth passage canine synoviocytes from 10 dogs were grown in hyperconfluent monolayer culture, formed into TSN, and then cultured for 3 weeks with 17.7% FBS or three human recombinant TSNgf (bFGF, TGF-ß1, and IGF-1). Cell viability was determined with laser microscopy. Histological architecture and the composition of fibrocartilage matrix were evaluated in TSN by staining tissues for glycosaminoglycan (GAG), α-smooth muscle actin, and collagen 1 and 2; quantifying the content of GAG, DNA, and hydroxyproline; and measuring the gene expression of collagens type 1α and 2α, the GAG aggrecan, and transcription factor Sry-type Homeobox Protein-9 (SOX9). Biomechanical properties were determined by materials testing force-deformation curves. The TSN contained components and histological features of mensical fibrocartilage extracellular matrix. Growth factor-treated TSN had higher DNA content but lower cell viability than TSNfbs. TSNgf had greater fibrocartilage-like matrix content (collagen 2 and GAG content with increased collagen 2α and SOX9 gene expression). Additionally, TSNgf collagen was more organized histologically and so had greater tensile biomechanical properties. The results indicate the potential of TSN when cultured with growth factors as implantable bioscaffolds for the treatment of canine meniscal deficiency.