[Atypical presentation of a carcinoid syndrome]. / Présentation atypique d'un syndrome carcinoïde

A 76-year-old woman presenting with right heart failure is reported. The investigation showed an ileal carcinoid tumour with multiple metastases and tricuspid regurgitation caused by a cardiac carcinoid lesion. Echocardiographic study and histopathological examination revealed typical characteristics of carcinoid heart disease. Nevertheless, except for the cardiac symptomatology, the patient did not show any other clinical manifestation of the carcinoid syndrome. Isolated right heart failure as the first sign of a carcinoid syndrome is rare; only two other cases have been described in the literature.

Float pool orientation.

Orienting new staff members to competently deliver care on a single unit is a challenging endeavor. This challenge escalates when orienting float staff members to 10 medical/surgical and 2 parent-child units. In this article, the authors describe the process for development and implementation of a competency-based orientation for float pool staff members. These principles also may be used to cross-train nursing staff members who occasionally float.

Clindamycin/primaquine versus trimethoprim-sulfamethoxazole as primary therapy for Pneumocystis carinii pneumonia in AIDS: a randomized, double-blind pilot trial.

The aim of this double-blind pilot trial was to compare clindamycin/primaquine with trimethoprim-sulfamethoxazole (TMP-SMZ) as primary treatment for AIDS-related Pneumocystis carinii pneumonia (PCP). The focus was on toxicity and tolerability since comparisons of efficacy were limited by the small sample size. Sixty-five individuals with a first episode of possible PCP were randomly assigned to receive clindamycin/primaquine (34 patients) or TMP-SMZ (31 patients). PCP was subsequently proven microbiologically in 27 and 22 of the patients in these respective groups. Half of the participants had an arterial partial oxygen pressure at enrollment of < or = torr. The incidence and severity of adverse reactions were lower--but not significantly lower (P = .07 and .08, respectively)--with clindamycin/primaquine. The markers of severity improved in a similar manner regardless of which regimen was administered. No significant differences were documented in outcome, duration of survival, length of the PCP-free interval, or rate of relapse. The results of this pilot study show a trend toward less toxicity with clindamycin/primaquine than with TMP-SMZ. This result must be confirmed by larger-scale clinical trials, which are also needed to better compare the efficacy of the two regimens.

[Sudden death in leukemic patients treated with doxorubicin]. / Mort subite chez des patients leucémiques traités avec daunorubicine.

Cardiotoxicity of the anthracycline antineoplastic drugs is well known, especially the chronic effects, manifested mainly as congestive heart failure. Fewer reports have been published about the acute cardiotoxicity of these medications, and risk factors associated with their use. Two cases of malignant arrhythmias leading to sudden death associated with severe hypokalemia are reported. These cases suggest a synergistic effect between anthracyclines and electrolyte disorders resulting in the acute cardiotoxicity of these drugs. The administration of these antineoplastic drugs should include regular and systematic control of serum electrolytes and correction of hypokalemia during treatment.

Cognitive impairments and depression in Parkinson's disease: a follow up study.

The presence of depression and cognitive impairments was examined in seventy patients with Parkinson's disease (PD). Forty nine patients of this original cohort were re-examined between three and four years after the first evaluation. While both depressed and non-depressed patients showed a significant decline in cognitive function during the follow up period, intellectual decline was significantly more severe for the depressed group. Depressed patients also showed a faster rate of progression of motor signs (mainly tremor) than the non-depressed group. Patients that died during the follow up period showed significantly more cognitive impairments than patients who were alive at follow up. These findings suggest that either there may be two forms of PD: one with depression and rapid cognitive decline and one without depression and a gradual cognitive decline; or that the mechanisms of cognitive impairment in PD and depression may interact to produce a more rapid evolution in cognitive impairment among PD patients with a previous depression than among patients without a previous depression.

Depression in Parkinson's disease.

A consecutive series of 105 outpatients with Parkinson's disease (PD) were examined for the presence of depression. Twenty-one percent met diagnostic criteria for major depression, 20% had minor depression, and the remainder were not depressed. The frequency of depression showed a bimodal distribution over time, with highest frequencies occurring in the early and late stages of the disease. Although other factors such as a positive family history of psychiatric disorders, quality of social functioning, and severity of tremor, rigidity, and akinesia did not show a significant association with depression, depressed patients had significantly higher impairment scores in activities of daily living and cognitive function than nondepressed PD patients. There was also a significant correlation between impairment and depression scores. In addition, among patients with mainly unilateral symptoms, depression was significantly associated with greater left hemisphere involvement. These findings suggest that depression in the early stages of the disease may be related to left hemisphere dysfunction, while later in the disease, depression and impairment in activities of daily living are interrelated. This may indicate more than one etiology of depression or that depression may have an adverse impact on the course of the disease.

Depression in patients with early versus late onset of Parkinson's disease.

We examined correlates of depression in patients whose onset of Parkinson's disease (PD) began before age 55 (early-onset group) compared with patients whose onset was after age 55 (late-onset group). The early-onset group showed a significantly higher frequency of depression than the late-onset group. When both groups were matched for duration of the disease, the early-onset group still showed a significantly higher frequency of depression, whereas tremor, akinesia, and rigidity were significantly more severe in the late-onset group. A stepwise regression analysis showed that in the early-onset group, depression scores were significantly correlated with scores of cognitive impairment and duration of the disease, while in the late-onset group, depression scores were significantly correlated with impairments in activities of daily living. These data suggest that depression in patients with early-onset PD may have a different etiology than in patients with late-onset PD.

Depression and cognitive impairment in Parkinson's disease.

Neuropsychological deficits including cognitive impairment as well as depression are among the most frequent and important mental disorders found in patients with Parkinson's disease (PD). It has never been determined, however, whether there is a specific relationship between cognitive impairment and depression. A consecutive series of patients with PD was therefore examined for the presence of depression and neuropsychological deficits. Severity of depression was found to be the single most important factor associated with the severity of cognitive impairment. When PD patients with major depression were compared with an age and stage-matched group of nondepressed patients with PD using a neuropsychological battery, major depressed patients performed significantly worse than the nondepressed patients on all aspects of neuropsychological function tested. These impairments were most pronounced on frontal lobe tasks.

Cognitive impairments in different stages of Parkinson's disease.

A consecutive series of 94 patients with Parkinson's disease (PD) were evaluated for the presence of depression and neuropsychological deficits. Patients were divided into groups based on the severity of their PD symptoms and then further subdivided into depressed and nondepressed groups. Both stage of PD and existence of depression had significant effects on neuropsychological performance. The nondepressed group with severe symptoms showed deficits in cognitive tasks involving motor speed, and the depressed patients with severe symptoms demonstrated impairments in frontal-lobe-related tasks.

PET imaging of cortical S2 serotonin receptors after stroke: lateralized changes and relationship to depression.

Patients with right-hemisphere strokes (N = 9) more than 1 year after injury had greater cortical binding of (3-N-[11C]methyl)spiperone than a similar group of patients with left-hemisphere strokes (N = 8) or normal control subjects (N = 17). The higher S2 serotonin receptor binding occurred in uninjured regions of the right parietal and temporal cortex. The ratio of binding in the ipsilateral to contralateral cortex showed a significant negative correlation with severity of depression scores in the left temporal cortex. These findings suggest that the biochemical response of the brain may be different depending on which hemisphere is injured and that some depressions may be a consequence of the failure to upregulate serotonin receptors after stroke.

Two-year longitudinal study of poststroke mood disorders: diagnosis and outcome at one and two years.

As part of a prospective study of mood disorders in stroke patients, interviews were obtained from 37 patients at 1 year and 48 patients at 2 years follow-up. In-hospital evaluations for these 65 follow-up patients found that 9 patients (14%) had symptom clusters of major depression, 12 patients (18%) had symptom clusters of dysthymic or minor depression, and 44 patients (68%) did not meet the DSM III diagnostic criteria for depression. Although overall prevalence of depression did not change significantly over time, the prognosis for individual patients, depending on diagnostic group, was different. All of the follow-up patients with major depression in-hospital were improved by 2 years, with a significant reduction in their mean depression scores and improvement in their activities of daily living, whereas only 30% of follow-up patients with dysthymic depression improved by this time. There was no significant improvement in their mean depression scores or mean activities of daily living score. Of the patients followed up who were not depressed in-hospital, 34% had developed major or minor depression by 2 years, and their mean depression scores were significantly increased. These data suggest that the prevalence of depression among the follow-up patients remains high (between 30 and 40%) for the first 2 years after stroke, but that untreated poststroke major depression has a natural course of about 1-2 years, with associated improvement in activity of daily living scores, whereas the prognosis for poststroke dysthymic depression is frequently unfavorable and often persists for greater than 2 years.

Screening for depression in stroke patients: the reliability and validity of the Center for Epidemiologic Studies Depression Scale.

This study examined the inter-observer reliability and validity of the Center for Epidemiologic Studies Depression Scale (CES-D) as a measure of depressive symptomatology in stroke patients, and its utility as a screening tool for depression in this population. The CES-D Scale is a brief questionnaire originally designed for use in community surveys. Twenty-seven non-aphasic patients enrolled in the Stroke Data Bank at the University of Maryland were interviewed by a research nurse using the CES-D. On the same day, each patient was independently evaluated by a research assistant using a psychiatric battery for depression and measures of cognitive, physical, and social functioning. Forty-one percent (11/27) of the patients were depressed according to clinical criteria for major or minor depression. With a cutpoint corresponding to the upper (most severe) 20% in community surveys, the CES-D Scale picked up 73% (8/11) of the depressed patients. In this sample no nondepressed patient scored over 16 on the CES-D (no false positives). The CES-D Scale scores correlated significantly with the other depression measures (r = .57 to r = .82, p less than .002) and did not correlate with the measures of cognitive, physical, or social functioning. Based on 24 patients who received a CES-D Scale score from both the nurse and the research assistant, inter-rater reliability was high (r = .76, p less than .001). Thus, the CES-D was found to be reliable and valid as a screening tool for assessing depression in stroke patients.

Mood disorders in left-handed stroke patients.

Thirty left-handed patients hospitalized for stroke were examined for mood disorders. Patients with left hemisphere lesions and nondominant hand impairments had significantly higher depression scores and more depressive diagnoses than patients with right hemisphere lesions and dominant hand impairments. Major depression was strongly associated with left anterior brain injury, and depression severity was significantly correlated with proximity of the lesion on CAT scan to the left frontal pole. These findings are almost identical to previously reported results from right-handed patients and suggest that cerebral lateralization of poststroke mood disorders may be independent of cerebral motor dominance and language dominance.

Social functioning assessment in stroke patients.

The influence of depression, intellectual function, and physical impairment on patient reports of social functioning was assessed by comparing responses obtained from 30 stroke patients with those obtained from an outside informant who knew the patient well. There was relatively good agreement between patient and other for both the overall score on the Social Functioning Examination (SFE) and individual items related to specific aspects of social functioning. Differences between scores obtained from a patient and outside informant were not significantly related to either depression, moderate degrees of intellectual impairment, relative closeness of patient and informant or to degree of physical impairment. These data suggest that valid SF assessments can be made either by a stroke patient who is capable of being interviewed or by a familiar outside informant. In addition, the prognostic utility of the SFE was examined by interviewing 50 patients during the acute stroke period and following them over six months. Social functioning in-hospital scores were not found significantly related to 6-month scores for either depression, intellectual impairment, or physical impairment, but depression and in-hospital impairment significantly predicted social functioning at 6-month follow-up. These data suggest that the most impaired stroke patients are the most likely to undergo social deterioration during the post-stroke period and may require the greatest amount of social intervention. Whether treatment of these variables significantly affects 6-month outcome remains an intriguing question for further study.

A positioning fixture for L-shaped rotating undercutting microknives.

A simple, inexpensive device which controls the insertion, positioning and withdrawal of cortical undercutting microkinives is described. The device aids the "rolling" insertion of an L-shaped microknife which produces a minimum amount of overlying tissue damage while it holds the knife steady during undercutting and allows the blade to be withdrawn by way of the same track through which it was inserted.

Mitotic activity of airway epithelium after short exposure to tobacco smoke and the effect of the anti-inflammatory agent phenylmethyloxadiazole.

Mitotic activity of extra- and intra-pulmonary airway epithelium has been studied in male rats exposed to tobacco smoke for 1, 2, 3, 7 or 14 days, with and without addition of the anti-inflammatory agent phenylmethyloxadiazole (PMO) to the tobacco. In both control and exposed animals the mitotic index is greater in extrapulmonary regions than intrapulmonary ones. A single exposure to tobacco smoke significantly increases mitotic activity in both airway regions. This initial level of mitotic response is not maintained but is rapidly restored by 1 day free from tobacco exposure: the second peak is as high as the first. Exposure to tobacco + PMO modifies timing and amplitude of the mitotic response. The effect of PMO is somewhat paradoxical since the first peak occurs later, i.e. after 2 days of exposure, but the increase is almost twice that seen after tobacco alone. The timing of the second peak is the same as after tobacco alone, but its amplitude is only half. In each experimental group the mitogenic effect is exerted on an intact epithelium. In animals exposed to tobacco alone, or tobacco + PMO, in extrapulmonary airways mitoses are located mainly in the basal region of the epithelium, whereas in intrapulmonary airways they are located mainly at the mid or superficial level.

Lidocaine plasma concentrations during and after endoscopic procedures.

Plasma lidocaine concentrations were intermittently measured in 8 upper gastrointestinal endoscopy and 12 bronchoscopy patients. The highest individual concentration was 0.98 microgram/ml in the upper gastrointestinal endoscopy patients and 3.79 microgram/ml in the bronchoscopy patients. Highest concentrations were reached at 15 minutes in the gastrointestinal endoscopy patients and at 30 or 60 minutes in the bronchoscopy patients. Thus, since lidocaine does not produce toxic effects at concentrations inferior to 6 microgram/ml, doses of this topical anaesthetic up to 16 mg/kg can be safely given during endoscopic procedures to patients with normal hepatic and cardiovascular functions. However, patients with liver metastases should be considered at high risk even if their liver function tests are normal. Patients at high risk of developing lidocaine toxicity should receive lower doses and be closely watched for at least 60 minutes after the end of the procedure.