Ultrasound-guided internal jugular venous cannulation: an introduction for non-radiologists to a technique that is here to stay.

The availability of relatively low-cost, portable ultrasound units has increased interest among non-radiologists in performing image-guided central venous cannulation, especially in high-risk patients. The essential elements of this relatively simple method of increasing the success and safety of internal jugular cannulation are presented.

Syncope and seizures of psychogenic origin: identification with head-upright tilt table testing.

Psychogenic seizures and psychogenic syncope are common disorders but are difficult to identify. Head-upright tilt table testing has emerged as a promising means of evaluating vasovagally mediated syncope and convulsive syncope. Of a total of 42 patients evaluated by head-up tilt for recurrent syncope and 10 evaluated for recurrent idiopathic seizures, a total of 5 patients experienced syncope and 3 had tonic-clonic seizure activity unaccompanied by any significant changes in blood pressure, heart rate, transcranial Doppler cerebral blood flow velocity, and electroencephalographic monitoring. Psychiatric evaluation revealed that seven patients suffered from conversion reactions and one from probable malingering. We conclude that patients who pass out or convulse during head-upright tilt without any change in physiologic parameters can be presumed psychogenic in origin and may be referred for psychiatric evaluation without further expensive diagnostic studies.

Characteristics of adopted juvenile delinquents.

There have been many reports describing the uniqueness of adopted children and adolescents' delinquent behaviors in terms of both their delinquent characteristics and courts' treatment of them. A total of 43 adopted juveniles, 32 extrafamilial (1.0%) and 11 intrafamilial (0.3%) adoptions were initially identified out of 3,280 juvenile delinquents. The adopted subjects were then compared with the demographically matched and offense matched nonadopted subjects. The family variables, such as marital and employment status of parents, were significantly different. However, there were only a few discernible trends, and in general there were no significant differences between the adopted and nonadopted juveniles in terms of their offense characteristics and dispositions.

Suicidal behavior among psychiatric outpatient children: an estimate of prevalence.

The prevalence of suicidal behaviors displayed by pre-adolescent psychiatric outpatients has been estimated to range between 25 percent and 33 percent of the outpatient population. The current study assessed suicidal behaviors displayed by 40 children aged 12 and younger who were evaluated in a psychiatric outpatient service. According to the Pfeffer Spectrum of Suicidal Behavior Scale, 15 percent of the sample had recently engaged in some form of suicidal behavior and almost 3 percent had made a suicide attempt that was viewed as realistically endangering life.

Suicidal behavior among psychiatric inpatient children: an estimate of prevalence.

The prevalence of suicidal behavior among pre-adolescent child psychiatric inpatients has been estimated to range between 18 and 80 percent of the inpatient population. This study is a chart review of the documentation of suicidal behaviors displayed by 45 consecutive child psychiatric inpatient admissions. According to the Pfeffer Spectrum of Suicidal Behavior Scale, 31 percent of the sample had recently engaged in some form of suicidal behavior and 9 percent had made a life-threatening attempt.

Cholinergic inhibition of cAMP accumulation in Sertoli cells cultured from immature hamsters.

Acetylcholine inhibits FSH-induced cAMP accumulation in cultured Sertoli cells from immature hamsters. This action of acetylcholine is mimicked by muscarinic cholinergic agonists with a rank order of carbachol greater than acetylcholine greater than arecoline greater than pilocarpine. The carbachol-induced inhibition of stimulated cAMP accumulation is blocked by atropine greater than pirenzepine but not by d-tubocurarine, indicating an apparent muscarinic receptor similar to that found in other peripheral tissues. The fact that pirenzepine is less effective as an inhibitor of the carbachol effect than atropine further defines the muscarinic effect as of the M2 subtype. The ability of carbachol to inhibit FSH-induced cAMP accumulation is blocked by pertussis toxin, which inhibits the action of the Ni inhibitory transducer of adenylate cyclase. These data indicate that cultured Sertoli cells from immature hamsters contain an M2 type muscarinic cholinergic receptor that is negatively coupled to the adenylate cyclase system through the inhibitory Ni transducer.

Tonic inhibition of adenylate cyclase in cultured hamster Sertoli cells.

Sertoli cells cultured from immature hamsters respond to FSH with a dose-related increase in cAMP accumulation. Pertussis toxin acts synergistically with FSH to stimulate cAMP accumulation. This effect of pertussis toxin indicates that Sertoli cell adenylate cyclase is under tonic inhibition due to the activity of the Ni inhibitory transducer. The acetylcholine receptor antagonists atropine or tubocurarine, or the opioid antagonist naltrexone, have no effect on the FSH-induced stimulation of cAMP accumulation, suggesting that neither acetylcholine nor opioids are responsible for the inhibition of Sertoli cell cyclase. While exogenous adenosine is inhibitory, adenosine deaminase augments the ability of FSH to stimulate cAMP accumulation, but not to the level of pertussis toxin. This indicates that the Sertoli cells produce endogenous adenosine that is at least partially responsible for the tonic inhibition of adenylate cyclase. Other possibilities for the tonic inhibition of cyclase include other Sertoli cell products, germ cell products, peritubular cell products or an action of FSH itself through both stimulatory and inhibitory transducers.

A follow-up study of 10 feminine boys.

Ten subjects who exhibited feminine behavior and cross-dressing as young boys are described. At follow-up, 8 to 10 years later, 4 are heterosexual, 2 are homosexual, 1 is transsexual, and the outcome is uncertain in 3. Of the eight who met DSM III criteria when evaluated, three are heterosexual, two are homosexual, one is transsexual, and the outcome is uncertain for two. Gender dysphoria appears to be a necessary but not sufficient factor in a transsexual outcome. The strength, rigidity, and persistence of cross-gender behavior through latency may be a good predictor of transsexual outcome.

Gender identity change in a female adolescent transsexual.

Two years of individual and milieu therapy are described of a 14 1/2-year-old girl who had presented with the persistent request to have a sex-change operation since age 12. Her past history was obtained from her parent and the records of the child guidance clinic which evaluated her at 3 years of age. She gives a history of remarkable tomboyism during her latency years and increasing withdrawal from peers and family during early adolescence. The patient's personal and family dynamics are explored, and these major therapeutic themes are discussed. The individual and milieu therapy are described and discussed with some speculation about the reasons for her positive response to psychotherapy. It would appear that this is a rare case of postpubertal female transsexual reported to have made a gender identity change.