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.

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.

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.

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.

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.

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.

Psychocutaneous disorders.

Dermatologic conditions are commonly associated with psychiatric sequella, eg, urticaria, alopecia, psoriasis, or acne. Moreover, the onset and course of dermatologic disorders may be significantly influenced by stress, emotional disturbances, or psychiatric disorder. Compulsions involving the skin, excoriations, or hair pulling (trichotillomania) are the more frequently encountered problems. In some cases, skin conditions are self-induced or reflect signs or symptoms of an underlying psychiatric disorder, including psychosis or obsessive-compulsive disorder. Additionally, skin lesions have been frequently described in case reports of factitious dermatitis. Finally, adverse effects of psychotropic drugs may cause dermatologic side effects, mostly idiosyncratic skin eruptions. These problems are discussed with emphasis on clinical features, comorbidity, and psychiatric management.

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.

Assessment of sexual functioning during the menstrual cycle.

In a study of 115 women who presented with complaints of premenstrual symptoms, we investigated the relationship between the menstrual cycle and different aspects of sexual functioning, using the Changes in Sexual Functioning Questionnaire. Women who were assessed at the screening visit during the late luteal phase of their menstrual cycle reported less desire to engage in sexual activity and less frequent sexual activity than women who were assessed during other phases of the menstrual cycle. The 24 women who returned for the second and third visits reported less frequent orgasms and less satisfaction from their orgasms premenstrually than during midcycle.

Female hypoactive sexual disorder: case studies of physiologic androgen replacement.

Menopause, surgical or naturally occurring, with reduced or deficient ovarian functioning has a major impact on morbidity and mortality in mid- to late life. A growing body of literature notes the role of androgens in maintaining women's health and emotional well-being. The administration of physiologic levels of testosterone replacement therapy as an adjunct to estrogen replacement requires further investigation. The Sexual Energy Scale was used to measure the patient's subjective experience of vitality or sexual energy with androgen replacement therapy. Three cases of women who had undergone a total abdominal hysterectomy with bilateral oophorectomy with complaints consistent with female hypoactive sexual desire disorder and free testosterone levels of < 2.0 pg/ml are presented. Physiologic androgen replacement is helpful in increasing sexual desire for some women.

Self-injurious behavior in elderly patients with dementia: four case reports.

Self-injurious behavior (SIB) is a polymorphous and poorly understood phenomenon, probably representing the final common pathway arising from a variety of etiologies. SIB is a clinical problem that affects elderly patients, but has received little attention. Although the specific prevalence rates of SIB in elderly patients with dementia is unknown, the lack of data is striking, considering the frequency with which geriatric psychiatrists may be consulted for these and related behavioral problems. The authors present four cases of elderly patients with SIB and dementia who responded favorably to psychopharmacologic treatment.

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.

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.

Depressive symptoms associated with gonadotropin-releasing hormone agonists.

The gonadotropin-releasing hormone (GnRH) agonists are a relatively new class of drugs that are potentially effective in treating disorders that are aggravated either by estrogen or testosterone. GnRH agonists are effective in the treatment of endometriosis, as well as other disorders, such as advanced prostrate cancer, precocious puberty and uterine leiomyomata. While the GnRH agonists reduce the extent of the endometrial lesions and the occurrence of pelvic pain associated with endometriosis, these agents are associated with physical and psychiatric side effects. The adverse effects of these agents are consistent with the physiological effects of ovarian suppression, such as vasomotor instability, vaginal dryness, and headaches. Preliminary results of a prospective, double-blind placebo-controlled study and an open label trial indicates that depressive mood symptoms increase in women treated with GnRH agonist therapy for endometriosis. Additional evidence suggest that sertraline effectively manages depressive mood symptoms associated with GnRH agonist therapy. The reason for the decline in mood on GnRH agonists is postulated to be associated with the decline in estrogen levels. Effective treatment strategies for depressive mood symptoms in women on GnRH agonists therapy may offer insight into the mechanisms of action of estrogen on mood.

The risk of missing angle neovascularization by omitting screening gonioscopy in acute central retinal vein occlusion.

OBJECTIVE: The purpose of the study was to determine whether angle neovascularization can occur without pupillary margin neovascularization in central retinal vein occlusion (CRVO). DESIGN: The study design was a prospective study of the main question and a retrospective study of ancillary issues. PARTICIPANTS: The authors examined 105 eyes of 100 patients with CRVO having clinical evidence of ischemia between July 1, 1986, and March 18, 1996. INTERVENTION: The authors looked for iris and angle neovascularization with both undilated slit-lamp biomicroscopy and Zeiss four-mirror gonioscopy. MAIN OUTCOME MEASURES: The presence of anterior segment neovascularization was measured. RESULTS: Of 34 eyes developing anterior segment neovascularization, 4 (12%) developed angle neovascularization without pupillary margin neovascularization over a mean follow-up of 2.2 +/- 2.4 standard deviation years. CONCLUSIONS: Angle neovascularization can occur without pupillary margin involvement in CRVO, implying the necessity of screening gonioscopy and supporting the Central Vein Occlusion Study conclusion (based on a photographic technique not used clinically).

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.