Lumbosacral nerve root avulsions: MR imaging demonstration of acute abnormalities.

Most of the previously reported lumbosacral nerve root avulsions presented with pseudomeningoceles at the time of delayed initial imaging. We report a case of traumatic lumbosacral nerve root injury associated with an isolated femur fracture and demonstrate the evolution of pseudomeningoceles following nerve root avulsions and edema in the perineural fat identified on the initial MR imaging.

Family management in the prevention of morbidity of schizophrenia. Clinical outcome of a two-year longitudinal study.

Environmental stress may contribute to the clinical morbidity of established cases of schizophrenia treated with optimal neuroleptic drugs. A family-based approach that aimed to enhance the problem-solving capacity of the index patient and his family caregivers was compared with a patient-oriented approach of similar intensity over a two-year period. Thirty-six patients who returned to stressful parental households after florid episodes of schizophrenia (CATEGO and DSM-III) were stabilized with optimal neuroleptics before being randomly assigned to family or individual therapy in a comprehensive community management program. After nine months, family-managed patients had fewer exacerbations of schizophrenia, lower ratings of schizophrenic psychopathology, fewer hospital admissions, and a trend toward lower deficit symptoms and reduced neuroleptic dosage. This reduced clinical morbidity was sustained throughout the second year of less intensive follow-up. The relative efficacy of the family approach in this clinical management study did not appear to be due to prognostic factors, rater bias, stressful life events, or the effectiveness of pharmacotherapy. Definitive tests of these findings with respect to efficacy require further well-designed studies.

Combined monoamine oxidase inhibitor-tricyclic antidepressant treatment: a pilot study.

Thirty newly hospitalized patients with RDC major or minor depressive disorder were randomly assigned to open treatment according to fixed dosage steps with 1) amitriptyline alone, up to a maximum dose of 300 mg/day; 2) tranylcypromine alone, up to a maximum dose of 40 mg/day; or 3) the combination of amitriptyline, up to 150 mg/day, and tranylcypromine, up to 20 mg/day. For 28 patients this protocol continued for 4 weeks or until discharge. As measured by the Hamilton and Zung depression scales, patients in all three treatment groups improved equally. The combination treatment produced a nonsignificantly higher frequency of minor side effects, none of which required discontinuation of treatment. The results indicate the feasibility and safety of further controlled clinical research with combined treatment, although caution is advised.

Breast-feeding reduces incidence of hospital admissions for infection in infants.

The prevalence of exclusive breast-feeding among infants 0 to 3 months of age in a community was contrasted with the prevalence of breast-feeding among infants hospitalized for the presence of presumed or established infections. During a one-year period, 136 infants, 0 to 3 months of age, were admitted to the hospital. Among the hospitalized group, only 11.0% were being exclusively breast-fed as contrasted with an expected frequency of 25.2% based on community feeding patterns. No bacterial infections were documented among the breast-fed group while 27 bacterial infections were documented among 121 non-breast-fed infants. This survey indicates that exclusively breast-feeding during the first three months of life significantly reduces the incidence of infections that ultimately require hospitalization of infants.

A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases.

A series of 33 patients with combined (injurious) sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorder (viz. "parasomnia overlap disorder") was gathered over an 8-year period. Patients underwent clinical and polysomnographic evaluations. Mean age was 34 +/- 14 (SD) years; mean age of parasomnia onset was 15 +/- 16 years (range 1-66); 70% (n = 23) were males. An idiopathic subgroup (n = 22) had a significantly earlier mean age of parasomnia onset (9 +/- 7 years) than a symptomatic subgroup (n = 11) (27 +/- 23 years, p = 0.002), whose parasomnia began with either of the following: neurologic disorders, n = 6 [congenital Mobius syndrome, narcolepsy, multiple sclerosis, brain tumor (and treatment), brain trauma, indeterminate disorder (exaggerated startle response/atypical cataplexy)]; nocturnal paroxysmal atrial fibrillation, n = 1; posttraumatic stress disorder/major depression, n = 1; chronic ethanol/amphetamine abuse and withdrawal, n = 1; or mixed disorders (schizophrenia, brain trauma, substance abuse), n = 2. The rate of DSM-III-R (Diagnostic and Statistical Manual, 3rd edition, revised) Axis 1 psychiatric disorders was not elevated; group scores on various psychometric tests were not elevated. Forty-five percent (n = 15) had previously received psychologic or psychiatric therapy for their parasomnia, without benefit. Treatment outcome was available for n = 20 patients; 90% (n = 18) had substantial parasomnia control with bedtime clonazepam (n = 13), alprazolam and/or carbamazepine (n = 4), or self-hypnosis (n = 1). Thus, "parasomnia overlap disorder" is a treatable condition that emerges in various clinical settings and can be understood within the context of current knowledge on parasomnias and motor control/dyscontrol during sleep.

The effect of hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral metabolism in neonates, infants, and children.

Cardiopulmonary bypass management in neonates, infants, and children often requires the use of deep hypothermia at 18 degrees C with occasional periods of circulatory arrest and represents marked physiologic extremes of temperature and perfusion. The safety of these techniques is largely dependent on the reduction of metabolism, particularly cerebral metabolism. We studied the effect of hypothermia on cerebral metabolism during cardiac surgery and quantified the changes. Cerebral metabolism was measured before, during, and after hypothermic cardiopulmonary bypass in 46 pediatric patients, aged 1 day to 14 years. Patients were grouped on the basis of the different bypass techniques commonly used in children: group A--moderate hypothermic bypass at 28 degrees C; group B--deep hypothermic bypass at 18 degrees to 20 degrees C with maintenance of continuous flow; and group C--deep hypothermic circulatory arrest at 18 degrees C. Cerebral metabolism significantly decreased under hypothermic conditions in all groups compared with control levels at normothermia, the data demonstrating an exponential relationship between temperature and cerebral metabolism and an average temperature coefficient of 3.65. There was no significant difference in the rate of metabolism reduction (temperature coefficient) in patients cooled to 28 degrees and 18 degrees C. From these data we were able to derive an equation that numerically expresses a hypothermic metabolic index, which quantitates duration of brain protection provided by reduction of cerebral metabolism owing to hypothermic bypass over any temperature range. Based on this index, patients cooled to 28 degrees C have a predicted ischemic tolerance of 11 to 19 minutes. The predicted duration that the brain can tolerate ischemia ("safe" period of deep hypothermic circulatory arrest) in patients cooled to 18 degrees C, based on our metabolic index, is 39 to 65 minutes, similar to the safe period of deep hypothermic circulatory arrest known to be tolerated clinically. In groups A and B (no circulatory arrest), cerebral metabolism returned to control in the rewarming phase of bypass and after bypass. In group C (circulatory arrest), cerebral metabolism and oxygen extraction remained significantly reduced during rewarming and after bypass, suggesting disordered cerebral metabolism and oxygen utilization after deep hypothermic circulatory arrest. The results of this study suggest that cerebral metabolism is exponentially related to temperature during hypothermic bypass with a temperature coefficient of 3.65 in neonates infants and children. Deep hypothermic circulatory arrest changes cerebral metabolism and blood flow after the arrest period despite adequate hypothermic suppression of metabolism.

Relationship between plasma desipramine levels and clinical outcome for RDC major depressive inpatients.

Depressed patients (N = 31), who met Research Diagnostic Criteria for major affective disorder-depressed, were severely ill and maintained drug-free for a 1-week period on inpatient status. They received a fixed dose (150 mg/day) of desipramine for a 4-week period with drug plasma level determination and clinical ratings performed at fixed time intervals throughout the study. Despite these rigid criteria for entrance and clinical outcome measures, no obvious relationship between plasma desipramine level and clinical outcome was found. The clinical implications of this finding are discussed.

The pharmacotherapy of septic shock.

Septic shock is a common clinical problem in the intensive care setting. The high mortality rate associated with septic shock, regardless of age, reflects the inadequacy of available therapeutic approaches. The purpose of this article is to review the current pharmacologic approaches to the treatment of septic shock with an emphasis on the pathophysiologic correlations of these treatments.

Quantitative ultrasound of the calcaneus as a screening tool to detect osteoporosis: different reference ranges for caucasian women, african american women, and caucasian men.

The interpretation of results measured by quantitative ultrasound (QUS) of the heel depends on the population studied. We measured estimated bone mineral density (BMD) of the heel using the Hologic Sahara sonometer. People were studied at county fairs, health fairs, and churches. Subjects were not on treatments that would affect bone density, other than calcium supplementation. This included 823 Caucasian women, 131 African American women, and 301 Caucasian men. In contrast to women, for Caucasian men the squared term for age was not significant, and a straight line of decline was the best fit for estimated BMD. African American women had a standard deviation larger than that reported by Hologic for Caucasian women. We compared a history of self-reported fractures with a subject's estimated BMD. An estimated BMD of 0.57 gm/cm2 included 75% of all fractures. This cutoff point was associated with increased fracture prevalence in subjects over age 50, relative risk of 1.4. This result corresponds to the Hologic data T-score of -0.2. When used as a screening tool for osteoporosis fracture risk, an estimated BMD of 0.57 gm/cm2 seems reasonable in those subjects over age 50.

Calcium, phosphorus, and alkaline phosphatase values of elderly subjects.

OBJECTIVE: To determine if significant gender differences existed between subjects 65 years of age and older, with regard to calcium, phosphorus, and alkaline phosphatase levels. DESIGN: A retrospective chart review of laboratory procedures performed in six different physician practices. The data consisted of 178 subjects representing 92 males and 86 females over the age of 65. DATA SOURCES: Patient data were obtained from the charts housed in a cardiac care center. Subjects, with charts preceding them, were referred by a physician to the cardiac center. The laboratory procedures had been performed previously in the laboratories of the referring physicians. MAIN OUTCOME MEASURES: After accounting for variation between laboratories, mean values of calcium, phosphorus, and alkaline phosphatase were examined to establish if a gender difference existed in patients over the age of 65. A blocked analysis of variance (ANOVA) was conducted at the 0.05 significance level. RESULTS: ANOVA analysis yielded significant gender differences for calcium, phosphorus, and alkaline phosphatase (p < 0.05). Females over the age of 65 consistently showed higher levels than males over the age of 65 for all three variables in five of the six laboratories studied. CONCLUSION: A statistically significant difference was found between the mean levels of men and women 65 years of age and older for calcium, inorganic phosphorus, and alkaline phosphatase. Gender and age are important variables to consider when analyzing and interpreting calcium, phosphorus, and acid phosphatase levels.

Family participation in the community rehabilitation of schizophrenics.

Families of schizophrenic patients frequently are ill equipped to handle the primary caretaking responsibilities that have fallen to them due to deinstitutionalization. The authors describe a program begun at a medical center in Southern California in 1978 to assist schizophrenic patients living at home and their families. The program, which consists of family therapy sessions in the home, focuses on education about schizophrenia, development of communication skills, and acquisition of structured problem-solving and other behavioral strategies. Preliminary findings of a controlled study of program participants suggest that the family interventions are both cost-effective and highly successful in reducing the incidence of relapse and hospitalization.

Family management in the prevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study.

Effective community treatment of schizophrenia involves not merely the removal of florid symptoms, but restoration of effective social role functioning. The efficacy of a family management approach is compared with an individual approach of similar intensity in terms of its impact on the patient's social adjustment after a florid episode of schizophrenia. Clinical reports, patient self-reports, and interviews with the family members of 36 patients, who were randomly assigned to family or individual management, demonstrated a consistent superiority for family management. The advantages for the family approach were sustained over a two-year period. The potential mechanisms through which the family approach may have achieved its greater efficacy are discussed from a multi-determined perspective.