Methods to improve diagnostic accuracy in a community mental health setting.

OBJECTIVE: This study determined the extent to which adding structured procedures improved diagnostic accuracy for outpatients with severe mental illness in a community mental health setting. METHOD: The Structured Clinical Interview for DSM-III-R (SCID) was used to interview 200 psychiatric outpatients. A research nurse reviewed medical records and amended the SCID diagnoses accordingly. A research psychiatrist or psychologist reviewed the diagnostic data and interviewed each patient to verify or further modify the previous findings. Diagnostic outcomes at each step of the procedure were compared to determine whether adding additional data improved diagnostic accuracy. The additional time required for each element of the diagnostic procedure was also assessed. RESULTS: Kappa comparisons of the different diagnostic levels showed that adding additional data significantly improved accuracy. Diagnoses rendered by combining the SCID and review of the medical record were the most accurate, followed by the SCID alone, and then diagnoses made by psychiatrists during routine care. In addition, the SCID alone identified five times as many current and past secondary diagnoses as were documented routinely in patients' charts. CONCLUSIONS: Combining structured interviewing with a review of the medical record appears to produce more accurate primary diagnoses and to identify more secondary diagnoses than routine clinical methods. The patients' knowledge of their diagnoses was limited, suggesting a need for patient education in this setting. Whether use of structured interviewing in routine practice improves patient outcomes deserves further study.

The effects of fluoxetine on the polysomnogram of depressed outpatients: a pilot study.

The effects of fluoxetine (FLU) and its active metabolite, norfluoxetine (NFLU), on the polysomnogram (PSG) of nine depressed outpatients (eight with major depression; one with bipolar II, depressed phase disorder) were investigated by contrasting PSG values prior to treatment and during administration of FLU. The PSG changes were correlated with daily dose, cumulative dosage, single serum concentrations, and the total area under the serum concentration curve (AUC) of both FLU and NFLU. Fluoxetine clearly increased both stage 1 sleep time and rapid-eye-movement (REM) latency and decreased both percent REM and REM density. With a few exceptions, the cumulative dosage of FLU and the AUC of FLU and NFLU were better predictors of the changes in awake and movement time in the PSG than single-sample concentrations of FLU and NFLU taken at the time of PSG assessment.

Five vs. ten days of therapy for acute otitis media.

In a double blind study 175 patients with acute otitis media were randomized into 2 treatment groups: 10 days of therapy with cefaclor or 5 days of therapy followed by 5 days of placebo. The dosage of cefaclor was 40 mg/kg/day administered orally in equally divided doses at 12-hour intervals. Tympanocentesis before treatment yielded specimens that contained Streptococcus pneumoniae or Haemophilus influenzae or both in 55% of specimens. Branhamella catarrhalis was isolated from 21% of specimens. Culture of material from the ear canal of patients with spontaneous perforation of the tympanic membrane of less than 24 hours duration yielded pneumococci or H. influenzae or both in 38% of specimens and staphylococci in 31%. Patients were scheduled for follow-up examinations at 5 or 6, 10, 30, 60 and 90 days. Of the 175 children 151 were evaluable at 10 days. There were 123 patients with both tympanic membranes intact at the time of diagnosis. There were 6 (10%) treatment failures of therapy in the 59 patients assigned to 5 days of therapy and 4 (6%) failures and 1 (2%) early relapse in the 64 assigned to 10 days of therapy (difference not significant). There were 28 evaluable patients with spontaneous perforation. There were 8 (53%) failures in the 15 children assigned to 5 days of therapy and only 1 (8%) failure in the 13 children assigned to receive 10 days of therapy (P = 0.016, Fisher exact test). Rates of reinfection and persistent middle ear effusion at 10, 30, 60 and 90 days follow-up were not significant different in patients assigned to 5 to 10 days of therapy. In patients with acute otitis media with intact tympanic membranes we have not been able to show any advantage of the standard duration of 10 days of therapy over a shortened course of 5 days. A 5-day course of antibiotic therapy does not appear to be sufficient for children with acute otitis media and spontaneous purulent drainage.

Slow-wave activity during non-REM sleep in men with schizophrenia and major depressive disorders.

Both major depressive disorders (MDD) and schizophrenia (SZ) have been associated with reductions in slow-wave (Stages 3 and 4) sleep, although these findings are controversial. The present study compared quantitative EEG measures of slow-wave activity (0.5-4 Hz) during non-REM (NREM) sleep among age-matched, symptomatic but unmedicated, depressed, schizophrenic and healthy control men (n=13/group). The amplitude of slow-wave activity (SWA) in the first NREM sleep period was significantly lower in both the MDD and SZ groups compared with controls. However, the time course of SWA, its accumulation and dissipation over all NREM sleep time, was abnormal in the MDD group but not in those with SZ. These findings suggest that the regulation of SWA is impaired in men with MDD but not in SZ. Thus, although those with SZ show reduced amplitude SWA in the first NREM period, there is no evidence that homeostatic regulation of SWA is impaired in this psychiatric group.

Characteristics of patients with substance abuse diagnoses on a general psychiatry unit in a VA Medical Center.

OBJECTIVE: The study examined characteristics associated with substance abuse among patients on a VA general inpatient psychiatry unit. METHODS: A total of 452 consecutive discharge summaries from a six-month period were examined for a recorded diagnosis of psychoactive substance abuse or dependence and evidence of negative social or health effects from the use of drugs or alcohol within one month of admission. The summaries were divided into three groups-no active substance abuse, active alcohol dependence, and two or more active substance dependencies. The demographic, diagnostic, and treatment outcome characteristics of the three groups were compared. RESULTS: Fifty-eight percent of the summaries included evidence of dependence on at least one substance. The three study groups differed in age, gender, racial mix, and psychiatric comorbidity. The group with no active substance abuse had an older mean age, included a higher proportion of women, and had a higher proportion of patients with bipolar disorder (manic), unipolar depression, and dementia. The group with two or more substance dependencies had a younger mean age, a higher proportion of African Americans, and a higher proportion of patients with cluster B personality disorders and schizophrenia. The group with alcohol dependence only was intermediate in age between the other two groups and had a racial mix similar to that of the group with no substance abuse. CONCLUSIONS: A high proportion of veterans seeking mental health care have substance dependencies. The relatively distinct profiles of the patients who abuse alcohol only and those who abuse more than one substance suggest the need for programs specifically tailored to each of these two groups.

A two-factor model of aggression.

This article synthesizes theoretical material from psychology research into a practical model for conceptualizing violence in psychiatric settings. Relevant research and theory are reviewed, focusing on two important behavioral models of aggressive behavior, hostile aggression and instrumental aggression. The concepts of reinforcement, anticipated rewards, specific and nonspecific stimulus-driven aggression, intermediary emotional states in aroused persons, and the aggression stimulus threshold are developed into a bimodal model applicable to the clinical management of violence. The model provides a broad framework for categorizing, understanding, and addressing aggressive behavior in clinical settings.

Juvenile laryngeal papillomatosis.

From the records of 23 patients with juvenile laryngeal papillomatosis, various aspects of the aetiology, natural history and treatment of the condition have been presented. The lesions are thought to be viral in origin, they are notoriously unpredictable in their behaviour, and treatment can often be prolonged and frustrating. Tracheostomy should be avoided, if possible, owing to the risk of further dissemination down the trachea and bronchi. The CO2 laser now seems to be the surgical treatment of choice, and early reports of adjuvant interferon therapy are encouraging. However, the laser is only available in certain centres, and interferon supplies are limited at present.

The transfer of free fatty acids across the human placenta.

Thirty-three matched maternal venous and umbilical cord vein and artery plasma samples were obtained at elective caesarean section and the concentrations of the individual free fatty acids determined. The maternal levels were 1.009 (SEM 0.043) and the umbilical vein-artery difference was 0.036 (SEM 0.011) mmol/l. There was a significant correlation between the mean concentration in maternal venous blood and the vein-artery difference for myristic, palmitic, stearic, linoleic and docosahexaenoic acids but not for oleic acid. When arachidonic acid concentration in the fetus was high, then the vein-artery difference was negative (flow to the placenta), when it was low, the difference was positive (flow to the fetus). Thus whilst there appears in general to be a flow of fatty acid to the fetus dependent on maternal free fatty acid concentrations, the transfer of arachidonic acid is largely determined by other factors. The reasons why oleic acid does not behave like the other fatty acids is not clear.

Energy intake and weight gain of very low birthweight babies fed raw expressed breast milk.

The energy intake and weight gain of low birthweight infants (under 1500 g) fed expressed breast milk were measured. Between the second and fourth weeks of life the mean energy intake was 577 kJ (138 kcals)/kg/day and the mean weekly increase in weight 119 g/week. Feeding energy-rich hind milk to two babies increased their energy intake but had little effect on their rate of weight gain. There appeared to be no correlation between energy intake and weight gain, probably owing to variation in the absorption of nutrients from expressed breast milk. This study forms a basis for a comparison of weight gain in babies fed alternative regimens of artificial milks.

Investigation of [14C] linoleic acid conversion into [14C] arachidonic acid and placental transfer of linoleic and palmitic acids across the perfused human placenta.

In five separate experiments in which single placental lobes were perfused, [14C] antipyrine, [3H] dextran and a fatty acid mixture containing [14C] linoleic and [3H] palmitic acids were added to the maternal circuit. Samples of fetal and maternal perfusate, taken at intervals, were analysed for radioactivity and fatty acid content. The relative placental transport rates of antipyrine, linoleic and palmitic acids and the changes in maternal and fetal circuit content of linoleic, palmitic and arachidonic acids were measured. Mean transfer rates of 150, 0.023 and 0.034 mumol min-1 were obtained for [14C] antipyrine, [3H] palmitic and [14C] linoleic acids, respectively. The transfer of [3H] dextran was negligible. The transfer rates of linoleic and palmitic acids did not differ significantly from one another. The maternal circuit content of palmitic and arachidonic acids increased, whereas linoleic acid content decreased. The fetal content of all three acid increased but in the case of arachidonic and palmitic acids the increase was not as great as that seen in the maternal circuit. In no experiment was radioactivity detected in maternal or fetal perfusate arachidonic acid. It is concluded that linoleic and palmitic acids cross the placenta from the maternal to the fetal side. This transfer appears to be non-selective. The large amounts of arachidonic acid that are released into the perfusate probably originate from placental lipids other than free linoleic acid.

Tuberculous meningitis: role of CT in management and prognosis.

Serial computed tomographic scans were performed during the course of tuberculous meningitis in 25 patients aged 1-70 years. Hydrocephalus rarely occurred without other abnormalities. Marked ventricular enlargement was associated with extensive basal enhancement. Basal meningeal enhancement was not a good indicator of the clinical state although marked enhancement was a risk factor for the development of basal ganglia infarction. Infarcts were much more common in children than in adults and were sometimes asymptomatic. Radiological abnormalities sometimes developed during treatment and often did not resolve completely. Many patients had severe residual neurological problems.

Malignant Post-Vietnam Stress Syndrome revisited.

Malignant Post-Vietnam Stress Syndrome describes a severe form of combat-related posttraumatic stress disorder. We update the concept of Malignant Post-Vietnam Stress Syndrome, considering the effects of repeated severe traumatization, exposure to atrocities, and a variety of comorbid conditions. An illustrative case report demonstrates an interdisciplinary treatment approach, combining case management, brief hospitalizations, symptom-directed use of medications, and supportive psychotherapy.

Rapid diagnosis of tuberculous meningitis by latex particle agglutination.

A simple latex particle agglutination test for the rapid detection of Mycobacterium tuberculosis plasma membrane antigen in cerebrospinal fluid was evaluated in 18 children with tuberculous meningitis and 134 control children with other disorders. The antigen was detected in all 18 patients with tuberculous meningitis, although an initial sample from 1 patient did not contain detectable antigen before it was concentrated. 133 of 134 control samples gave negative results.

Paradoxical expansion of intracranial tuberculomas during chemotherapy.

4 patients with tuberculosis, 3 of whom had tuberculous meningitis, were noted to have tuberculomas on computed tomographic scanning. During antituberculous chemotherapy the intracranial lesions increased in size in all 4 patients at a time when the clinical state and cerebrospinal-fluid abnormalities were improving; in 2 of the patients the regional lymph nodes also enlarged greatly. Though the expansion of the cerebral lesions caused anxiety and led to some changes in chemotherapy, the lesions eventually diminished in size.

The calorie intake and weight gain of low birth weight infants fed on fresh breast milk or a special formula milk.

The calorie intake and weight gain of 24 low birth weight (LBW) infants, less than 33 weeks gestation and less than 1500 g birth weight, was studied prospectively. Fourteen infants were fed on a commercially available LBW formula milk and ten were fed on their own mother's fresh unpasteurised expressed breast milk (EBM). The difference between the two feeding groups in the intake of milk and calories was not significant, but from the third week onwards those fed on the LBW formula gained weight faster. The mean (+/- SEM) weight increments for weeks 3-6 (inclusive) for LBW formula and EBM fed infants was 189.3 (+/- 7.9) and 139.6 (+/- 11.1) g/wk respectively (P less than 0.001). The LBW formula was well tolerated and is a suitable feed for LBW infants. However some babies thrived well on fresh EBM and so we are continuing to encourage mothers who wish, to breast feed their own preterm infants. When such infants fail to thrive it is appropriate to supplement with a LBW formula.

Treatment of respiratory papillomatosis with adenine arabinoside.

Nine children with respiratory papillomatosis have been treated with adenine arabinoside with limited success. No long term benefit was obtained in six, and although resolution was achieved in one and probably two others, this could not be attributed confidently to treatment.