Long-term outcome of renal transplantation at a university center in Rio de Janeiro between 1975 and 2000.

This study reports the 25-year experience of a single university center with respect to the impact of selected variables on long-term survival and half-life of 742 transplants. We calculated 1-, 5-, and 10-year Kaplan-Meier survival rates for grafts and patients, with separate analyses for HLA match and for each quinquennium. We also investigated the impact of cyclosporine administration and OKT3 induction. Global graft and patient survival rates were 85.2%, 61.0%, and 43.5% and 93.0%, 78.9%, and 66.6% for 1, 5, and 10 years, respectively. The half-life of 23.3 years for the 105 HLA-identical transplants was significantly better (P <.0001) than that for all other matches. Half-lives for 319 1-haplotype matched, 116 living-unrelated, and 153 cadaver grafts were 8.2, 5.7, and 5.6 years, respectively. No survival advantage was noted among these other matches. Introduction of cyclosporine in all non HLA-identical transplants and OKT3 induction for cadaver grafts conferred significant survival advantages compared with no use (P =.0002 and P =.009). There has been a continuous improvement in the long-term results in each quinquennium studied.

Personality and substance use disorders as predictors of criminality.

The study objective was to evaluate the relationship between a personality disorder (PD) diagnosis and criminal behavior among drug- and alcohol-dependent patients both retrospectively and prospectively. We examined 1-year pretreatment and 1-year post-treatment crime rates among 370 drug- and/or alcohol-dependent patients. Hierarchical logistic regression was used to examine the predictive value of DSM-III-R PD diagnoses after controlling for demographic features and type and severity of substance dependence. Patients with a diagnosis of antisocial PD (ASPD) were more likely to report having committed a variety of crimes, including violent crimes, during the pretreatment period. Individuals with more PD diagnoses or a diagnosis of borderline PD (BPD) or schizoid PD also reported a greater number of pretreatment violent crimes. In addition, the number of PD diagnoses was correlated with the number of crimes against property. During the pretreatment period, significant interactions were also found between PD measures and substance use in relation to both property crimes and violation of parole or probation. During the posttreatment period, a diagnosis of BPD predicted the commission of violent crimes. In contrast, a cluster A PD predicted a lower frequency of crimes against property. ASPD did not predict criminality during the 1-year follow-up period. In conclusion, a PD diagnosis, particularly ASPD, was associated with a variety of criminal behaviors during the 1-year period preceding substance abuse treatment. Following treatment, PD diagnosis had limited value in the prediction of criminal behavior. Possible explanations for these findings are discussed.

Plasma concentrations of endogenous benzodiazepine-receptor ligands in patients with hepatic encephalopathy: a comparative study.

OBJECTIVE: Hepatic encephalopathy (HE) is a complex neuropsychiatric disorder secondary to acute or chronic liver failure. Although the exact causes of HE have not been clarified, enhanced central nervous system inhibition at the gamma-aminobutyric acid (GABA)-benzodiazepine receptor complex, mediated by increased levels of endogenous benzodiazepine-receptor ligands (BZRL), has been proposed. Research exploring this hypothesis has yielded contradictory findings. This study evaluated the presence and levels of BZRL in plasma from patients with HE and 3 comparison groups. DESIGN: Cross-sectional study. PATIENTS: Twenty-four patients with HE, 10 patients with liver cirrhosis without encephalopathy (LC), 4 patients with uremic encephalopathy (UE), and 9 healthy subjects. INTERVENTIONS: Radio-receptor assay of plasma samples from patients and controls. MAIN OUTCOME MEASURES: Plasma levels of BZRL. RESULTS: The patients in the HE group had significantly higher plasma BZRL levels than the patients with UE and the healthy subjects, but not than those with LC, in whom these compounds were also detected in significant concentrations. When patients were classified according to the severity of HE, plasma of BZRL showed a modest correlation with stage of severity (r = 0.37). Interestingly, approximately one-third of the patients with HE did not have detectable levels of BZRL. CONCLUSION: Endogenous BZRL may play a role in the pathogenesis of HE, although neuropsychiatric symptoms in HE are difficult to explain in terms of these compounds alone.

Association of alcohol or other drug dependence with alleles of the mu opioid receptor gene (OPRM1).

Opioidergic neurotransmission and, specifically, the mu opioid receptor have been implicated in the reinforcing effects of a variety of drugs of abuse. Consequently, the present study examined the association of a polymorphic (CA)n repeat at the OPRM1 locus (the gene coding for the mu opioid receptor) to alcohol or drug dependence in 320 Caucasian and 108 African-American substance-dependent or control subjects. Among Caucasians, suggestion of a modest association, which could be interpreted as statistically significant (p = 0.03), was observed between OPRM1 alleles and substance (alcohol, cocaine, or opioid) dependence. Analysis by specific substance showed only a trend level association to alcohol dependence. Comparisons among African Americans yielded no evidence for association. Further studies of the association between alleles of the OPRM1 gene and substance dependence appear warranted, particularly if they use a family-based approach to control for population stratification. Phenotypes other than a broad diagnostic categorization, such as opioid antagonist effects on drinking behavior in alcoholics, may provide more consistent evidence of a role for OPRM1 in behavioral variability.

Treatment of inhalant-induced psychotic disorder with carbamazepine versus haloperidol.

OBJECTIVE: The efficacy and adverse effects of carbamazepine and haloperidol were compared in the treatment of inhalant-induced psychotic disorder. METHODS: Forty male patients admitted to an acute psychiatric unit for treatment of inhalant dependence and inhalant-induced organic mental disorder, as diagnosed by DSM-III-R, were randomly assigned to receive five weeks of treatment with carbamazepine or haloperidol in identical-appearing capsules. The Brief Psychiatric Rating Scale and the DiMascio Extrapyramidal Symptoms Scale were administered weekly. RESULTS: Both treatment groups improved significantly over time. A reduction of symptom severity of 48.3 percent in the carbamazepine group and 52.7 percent in the haloperidol group was observed. Approximately half the patients in each group were considered treatment responders at the end of the study. Adverse effects were significantly more common and more severe in the haloperidol group. CONCLUSIONS: Carbamazepine appears to have comparable efficacy but fewer adverse effects than haloperidol for the treatment of inhalant-induced psychotic disorder.

Suicide rate following attendance at an accident and emergency department with deliberate self harm.

OBJECTIVE: To determine the risk of suicide in patients attending an accident and emergency (A&E) department with deliberate self harm. METHODS: Information was obtained on suicides and open verdicts from the coroner's office and cross checked with computerised records in the A&E department. RESULTS: There was a trend to suicide among younger socially isolated males and older females. CONCLUSIONS: There is a significant association between suicide and a previous attendance at A&E with deliberate self harm. Appropriate assessment of these patients is an efficient way of managing self harm.

Insulin dependent diabetes mellitus and deliberate self-harm.

Patients who deliberately harm themselves can present with a variety of disorders. The case is reported of a patient who deliberately self-harms by inducing hypoglycaemic episodes. This patient has placed great demands on the emergency services over the last 9 years. Early involvement by senior accident and emergency staff is advised.

Using a metal detector to locate a swallowed ring pull.

A 48-year-old man accidently swallowed the ring pull from a soft drink can. He complained of pain in his chest. Chest radiographs were normal. A metal detector emitted a strong response when passed across the front of his chest. Oesophagoscopy was carried out and the ring pull was successfully removed. We recommend the wider use of metal detectors by accident and emergency (A&E) department staff particularly when dealing with patients who have ingested metals of low radiodensity.

Head injuries in the accident and emergency department: are we using resources effectively?

This paper reports a retrospective criterion based audit which reviewed head injury management in two accident and emergency (A&E) departments. Management was compared with regionally agreed criteria for ordering a skull radiograph (SXR) and a computerized tomogram (CT scan) and for admission, and the quality of medical documentation was assessed. A total of 158 patients were reviewed and 132 patients (84%) satisfied the three key areas of recommended head injury management. Failures to satisfy recommended guidelines were present in 19 patients (12%) for SXR, four (2%) for admission and three (2%) for CT scanning. Three skull fractures (two in young babies) would have been missed if the criteria had been adhered to strictly. There was one adverse outcome when a patient who should have been admitted returned to A&E 8 days after initial attendance with a subdural haemorrhage and died shortly afterwards. Apart from 'loss of consciousness', the quality both in content and legibility of the medical documentation was poor. The result of 84% correctly managed patients may be over-optimistic according to the criteria used. Although criteria have a valuable role to play, there are problems with prescriptive standard setting. A recommendation was made to develop a head injury pro forma to address the poor quality medical documentation and it was also recommended that the SXR, CT scan and admission criteria for babies and young children be reviewed.

Use of a pro forma for head injuries in the accident and emergency department--the way forward.

The aim of this study was to assess the quality of documentation of head-injured patients seen in three accident and emergency (A&E) departments using a specially designed head injury pro forma. A 4-week prospective study of a single head injury pro forma was followed by a second similar study with an improved version (two head injury pro formas, one for young children and babies, the other for older children and adults). The main outcome measures were the degree of completion of the pro forma and questionnaire responses from receptionists, nurses and doctors. A total of 1260 patients had their details completed on the pro forma in both studies. Compared with standard hand written A&E notes, the degree of completion of clinical details specific to the head injury were high, eg. over 95% for symptoms. The pro forma was generally well received by A&E staff, particularly after recommended improvements were made, and the majority of staff felt it should be introduced permanently into the A&E department. Concern about its use in cases of very minor head injury and multiple injuries were raised. As well as improved documentation, the pro forma facilitates the process of audit and may have an important role to play in information technology and computers in the future.

Introduction of a trauma team to a district general hospital. The Brighton Experience.

The response to major trauma in Britain has been demonstrated to be inadequate. One of the suggested approaches to tackling the problem has been the setting up of rapid response trauma teams at district general hospitals. We set up such a team in Brighton and report on its first year of operation. Numbers of patients were not sufficient to draw any firm conclusions, though no dramatic improvement in outcome was evident. Problems in setting up such a team are discussed.

Meningite por Leptospira: casuistica derivada, na cidade de Sao Paulo, de surto epidemico de doenca meningococica. / Leptospira meningitis: material collected in the city of Sao Paulo, from a meningococcal disease outbreak

Na cidade de Sao Paulo (Estado de Sao Paulo, Brasil) ocorreu, de 1971 a 1975, surto epidemico de doenca meningococica. Essa circustancia fez com que acometimentos identificados como meningite asseptica ou linfomonocitaria ficassem comumente reconhecidos, permitindo aos Autores espuculacao destinada a verificar quantos eram devidos a infeccao por Leptospira. Foi entao comprovado, atraves de prova de soro-aglutinacao, que 4,8% de 144 doentes estavam com leptospirose, clinicamente traduzida por manifestacoes que nao envolveram expressiva gravidade e, tambem, habitualmente nao se afiguram orientadoras no sentido de suscitar especifica cogitacao diagnostica

Efficacy of various drugs for treatment of giardiasis. A comparative study.

A total of 172 patients with giardiasis were treated with four of the drugs most commonly used for this infection. All drugs were used in their usual posologic schedules. The cure rates achieved with furazolidone, nimorazole, metronidazole, and tinidazole were; respectively, 72%, 94%, 87%, and 97%, while in a control group given no medication stools of only 35% of the patients became negative. Side effects were of minor importance in patients treated with nimorazole and metronidazole, and were somewhat more frequent and severe in those treated with furazolidone. Tinidazole produced no side effects.