A seismic reflection image for the base of a tectonic plate.

Plate tectonics successfully describes the surface of Earth as a mosaic of moving lithospheric plates. But it is not clear what happens at the base of the plates, the lithosphere-asthenosphere boundary (LAB). The LAB has been well imaged with converted teleseismic waves, whose 10-40-kilometre wavelength controls the structural resolution. Here we use explosion-generated seismic waves (of about 0.5-kilometre wavelength) to form a high-resolution image for the base of an oceanic plate that is subducting beneath North Island, New Zealand. Our 80-kilometre-wide image is based on P-wave reflections and shows an approximately 15° dipping, abrupt, seismic wave-speed transition (less than 1 kilometre thick) at a depth of about 100 kilometres. The boundary is parallel to the top of the plate and seismic attributes indicate a P-wave speed decrease of at least 8 ± 3 per cent across it. A parallel reflection event approximately 10 kilometres deeper shows that the decrease in P-wave speed is confined to a channel at the base of the plate, which we interpret as a sheared zone of ponded partial melts or volatiles. This is independent, high-resolution evidence for a low-viscosity channel at the LAB that decouples plates from mantle flow beneath, and allows plate tectonics to work.

A staff dialogue on do not resuscitate orders: psychosocial issues faced by patients, their families, and caregivers.

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a non-profit organization dedicated to supporting and advancing compassionate health care delivery which provides hope to the patient, support to caregivers, and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. The following case of a woman who developed lymphoma was discussed at the July and August, 1997 Schwartz Center Rounds. There were considerable delays and uncertainties in the diagnosis, which was followed by an unpredictably chaotic clinical course. Although she had made it clear to her doctor that she did not want "heroic measures," she had unexpectedly rallied so many times that her son and her husband wanted her doctors to do everything possible to keep her alive, including the performance of cardiopulmonary resuscitation (CPR). The clinical benefit of CPR in the event of cardiac arrest in those with cancer is discussed, as are do not resuscitate (DNR) orders, living wills, and healthcare proxies. In addition, the issues that surround DNR status, including who should discuss DNR status with a patient, and how and when it should be discussed, are reviewed. Staff raised concerns about the effect of discussing DNR status on the doctor-patient relationship, and wondered whether writing DNR orders adversely affect the care of patients.

The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general medical setting. The Academy of Psychosomatic Medicine.

This practice guideline seeks to provide guidance to psychiatrists who regularly evaluate and manage patients with medical illnesses. The guideline is intended to delineate the knowledge base, professional expertise, and integrated clinical approach necessary to effectively manage this complex and diverse patient population. This guideline was drafted by a work group consisting of psychiatrists with clinical and research expertise in the field, who undertook a comprehensive review of the literature. The guideline was reviewed by the executive council of the Academy of Psychosomatic Medicine and revised prior to final approval. Some of the topics discussed include qualifications of C-L consultants, patient assessment, psychiatric interventions (e.g., psychotherapy, pharmacotherapy), medicolegal issues, and child and adolescent consultations.

Dizziness and panic disorder: a review of the association between vestibular dysfunction and anxiety.

Dizziness is a common and costly condition that causes significant distress and impairment yet often confounds appropriate diagnosis and treatment. Among patients presenting for evaluation and treatment of dizziness, rates of panic disorder are elevated to 5 to 15 times the general population rates. In addition, the limited studies to date of dizziness in patients with panic disorder suggest that panic patients frequently experience significant dizziness and often demonstrate evidence of vestibular dysfunction. In this paper we review studies investigating the relationship between panic disorder and vestibular dysfunction. Currently, there are three main explanatory models for the association between panic disorder and vestibular dysfunction: the psychosomatic model, the somatopsychic model, and the network alarm theory. Systematic investigations of the treatment of patients with vestibular symptoms and panic disorder are lacking, though prevalence, associated costs, and disability suggest that they are needed. Serotonin selective reuptake inhibitors are good candidates for future treatment studies.

A prospective multicenter study of competency evaluations by psychiatric consultation services.

Psychiatric consultation for assessment of competency is common but infrequently studied. Past studies have used chart reviews. The authors prospectively studied 88 consecutive psychiatric consultations at 3 centers. Competency evaluation was performed to determine whether the patient could 1) sign out of the hospital against medical advice (AMA) (N = 16); 2) give informed consent (N = 16); 3) take care of him-/herself (N = 33); 4) refuse medical care (N = 24); or 5) deal with other matters (N = 12). Patients with a favorable risk-benefit ratio were more likely to be seen in consultation compared with those with an unfavorable ratio. Patients in whom there was concordance in the assessment of the psychiatric consultant and the referring physician (N = 61) were more likely to be male, single, to have psychotropics recommended, to sign out AMA, and to be discharged from the hospital. Patients in whom there was disagreement between the consultee and the consultant merits further study.

Management of the prescription-drug-dependent adult: case of meprobamate abuse and its treatment.

Misuse of prescription drugs in the elderly can be a serious problem that is difficult to manage. Prescriptions for non-narcotic central nervous system (CNS) depressants (e.g., anxiolytics and sedative-hypnotics) are commonly written, and their use is associated with severe intoxication and withdrawal effects. The presence of comorbid psychiatric conditions (e.g., depression or panic disorder), for which these agents are prescribed frequently, complicates the clinical picture. This paper, using case examples of meprobamate abuse, describes how physicians can recognize, manage, and treat a patient who is abusing a non-narcotic CNS depressant.

Failure to record delirium as a complication of intra-aortic balloon pump treatment: a retrospective study.

This study was conducted to determine whether or not diagnosis and treatment of delirium among patients treated with the intra-aortic balloon pump (IABP) correlates with the recording of this complication on discharge records. Since prior episodes of delirium are one of the few clear risk factors for future episodes of delirium, accurate recording of delirium on the discharge summary and list of discharge diagnoses is useful to clinicians. A retrospective review of the charts of all patients (N = 198) who underwent placement of an IABP during 1988; assessment of the type and frequency of medical and neuropsychiatric complications during IABP treatment; and comparison of chart review findings with the Massachusetts General Hospital's computer-generated lists of discharge diagnoses for the same IABP-treated patients was completed. Only 12% of patients diagnosed and treated for delirium had delirium recorded as a discharge diagnosis. In contrast, 44% and 52% of patients who had been diagnosed and treated for cerebrovascular accident and pneumonia, respectively, had these diagnoses recorded among the discharge diagnoses. Receiving a discharge diagnosis of organic brain syndrome increased the likelihood that delirium was recorded as a discharge diagnosis. Delirium is underdiagnosed as a complication associated with IABP-treatment and is under-reported on the list of discharge diagnoses, even when it is diagnosed. Further study is warranted to determine if making the diagnosis of delirium during a patient's hospital course and recording it is a complication at the time of discharge is translated into a higher level of preparedness by physicians during subsequent hospitalizations.

The association between intravenous haloperidol and Torsades de Pointes. Three cases and a literature review.

Torsades de Pointes (TDP) is a potentially malignant ventricular arrhythmia that often has a drug-induced origin. Oral, but not intravenous, haloperidol has been generally associated with this arrhythmia. The authors detail three patient cases of TDP that occurred while the patients were receiving intravenous haloperidol. The authors discuss the known risk factors for the development of TDP and review the literature on ventricular arrhythmias associated with haloperidol use.

Neuropsychiatric manifestations of systemic lupus erythematosus.

The authors critically review the literature describing the varied neuropsychiatric syndromes associated with systemic lupus erythematosus (SLE). Factors that have complicated the identification and treatment of affective, behavioral, and cognitive disturbances in these patents are identified, and the utility of various diagnostic interventions is examined. Finally, the authors outline the role of the consultation-liaison psychiatrist in the clinical management of the SLE patient with neuropsychiatric disturbances.

Neuroleptic malignant syndrome associated with clozapine treatment.

Although not universally accepted, evidence exists that clozapine treatment may be associated with neuroleptic malignant syndrome (NMS). To date, 10 cases of NMS associated with the use of clozapine have been reported in the literature. We report two more cases of NMS in patients on clozapine treatment and review the clinical presentations, biochemical features, risk factors, treatment, and rechallenge with neuroleptics in all reported patients who developed NMS while receiving clozapine treatment. An update and critical review of clozapine-induced NMS are also presented. Clozapine treatment can cause NMS similar to that induced by conventional neuroleptics. A history of NMS, existing brain insults, low serum iron concentrations, and being a young male may be risk factors for the development of NMS associated with clozapine treatment. NMS most commonly occurs when clozapine is being used along with other psychotropics. Early recognition of the syndrome and cessation of clozapine when NMS occurs are advised. Supportive care and use of dopamine agonists and dantrolene may be helpful in treating clozapine-associated NMS. These results support the notion that clozapine can cause NMS. However, NMS associated with clozapine treatment is a rare event. When it happens, the clinical presentation, risk factors, and management appear to be similar to those of NMS associated with conventional neuroleptics.

The Massachusetts General Hospital annotated bibliography. For residents training in consultation-liaison psychiatry.

The annotated bibliography for the resident's division of the Avery D. Weisman Psychiatry Consultation Service at the Massachusetts General Hospital (MGH) equips the residents with a practical knowledge in consultation-liaison (C-L) psychiatry for their forays onto the floors of the general hospital. As an annotated bibliography, it is not intended to be a comprehensive source for C-L training. However, the basic fund of knowledge prepares MGH's psychiatric residents in a practical way for the variety of questions posed to the C-L service. The authors present this annotated bibliography as a guide for future efforts to establish a core content of knowledge for residents training in C-L psychiatry.