Hepatitis C virus infection in cocaine users--a silent epidemic.

Over a recent three year period, approximately 600 individuals responded to newspaper advertisements for research studies requiring healthy, cocaine using subjects. These subjects were screened using a standard phone interview in order to eliminate individuals with known medical or psychiatric illnesses that would exclude them from ongoing neuroimaging studies of drug abuse. Individuals were specifically asked about their hepatitis and HIV status. Of these, 170 subjects passed the phone screen, having no known medical or psychiatric illness outside of cocaine abuse/dependence and were willing to be further evaluated for the studies. These subjects were brought to the Medical College of Wisconsin's General Clinical Research Center and tested for, among other measures, hepatitis B, hepatitis C, and HIV. Of these, 144 completed the examination and all testing. In this cohort of assumed healthy subjects, 47 (33%) tested positive for antibodies to the hepatitis C virus (HCV). Only 7 (5%) tested positive for the hepatitis B surface antigen and 2 (1.4%) to HIV. The demographics of this cohort are 56% African-American, 81% male, 75% never-married, 55% unemployed with a mean age of 36 years. The percentage of subjects reporting any lifetime intravenous drug use among the HCV(+) and the HCV(-) cohorts was 77% vs. 29% respectively. Some routes of HCV transmission are still unclear and may reflect lifestyle or other factors related to cocaine use outside of parenteral drug use. Since almost all HCV infections become chronic, and many progress to chronic active hepatitis, cirrhosis, and ultimately hepatocellular carcinoma, these observations suggest a significant epidemic in an unsuspecting population with little regular access to health care. These individuals also form a large pool for the continued transmission of HCV to the general population. Additional public health interventions are suggested.

Gastric outlet obstruction as a late complication of formaldehyde ingestion: a case report.

A patient who ingested formaldehyde in a suicide attempt is described. Although early clinical and endoscopic manifestations appeared relatively mild, after several weeks the patient developed signs and symptoms suggestive of gastric outlet obstruction that eventually required surgical intervention. Formaldehyde ingestion has only rarely been described in the literature. Formaldehyde is a corrosive that can produce late sequelae, similar to the more common ingestion of acids and alkali.

Determination of drug-induced changes in functional MRI signal using a pharmacokinetic model.

As the applications of functional magnetic resonance imaging (fMRI) expand, there is a need for the development of new strategies for data extraction and analysis that do not require the presentation of stimuli in a repeated on/off pattern. A description and evaluation of a method and computer algorithm for the detection and analysis of brain activation patterns following acute drug administration using fMRI are presented. A waveform analysis protocol (WAP) input function has been developed that is based upon the single-dose pharmacokinetics of a drug of interest. As a result of this analysis, regional brain activation can be characterized by its localization and intensity of activation, onset of action, time to peak effect, and duration of action. A global statistical test for significant drug effects based upon the probability of a voxel being activated by a saline vehicle injection is applied to grouped data on a voxel by voxel basis. Representative data are presented using nicotine as a prototypical agent. Using this method, statistically significant drug-induced brain activation has been identified in several key cortical and subcortical brain regions.

Abnormal cerebral activation associated with a motor task in Tourette syndrome.

BACKGROUND AND PURPOSE: In Gilles de la Tourette syndrome, PET scanning and EEG suggest an abnormal organization of the sensorimotor cortex and basal ganglia. The purpose of this study was to use functional MR imaging to study activation in the sensorimotor cortex in patients with Tourette syndrome. METHODS: From echo-planar images acquired during intermittent performance of a finger-tapping task, the location of activated pixels was determined by means of conventional signal processing methods. In five patients with Tourette syndrome and five healthy volunteers, the number of activated pixels in the sensorimotor cortices and supplementary motor areas were counted. The area over which the activation was distributed was calculated. RESULTS: In the five patients, the average number of pixels activated during the finger-tapping task in the sensorimoter cortices and supplementary motor area (69.4 pixels) exceeded that in the volunteers (49.2 pixels). The difference was significant. The area over which the pixels was distributed was significantly larger (25.4 vs 13.8 cm2). CONCLUSION: Motor function is organized differently in patients with Tourette syndrome than in healthy subjects.

Nicotine-induced limbic cortical activation in the human brain: a functional MRI study.

OBJECTIVE: Nicotine is a highly addictive substance, and cigarette smoking is a major cause of premature death among humans. Little is known about the neuropharmacology and sites of action of nicotine in the human brain. Such knowledge might help in the development of new behavioral and pharmacological therapies to aid in treating nicotine dependence and to improve smoking cessation success rates. METHOD: Functional magnetic resonance imaging, a real-time imaging technique, was used to determine the acute CNS effects of intravenous nicotine in 16 active cigarette smokers. An injection of saline followed by injections of three doses of nicotine (0.75, 1.50, and 2.25 mg/70 kg of weight) were each administered intravenously over 1-minute periods in an ascending, cumulative-dosing paradigm while whole brain gradient-echo, echo-planar images were acquired every 6 seconds during consecutive 20-minute trials. RESULTS: Nicotine induced a dose-dependent increase in several behavioral parameters, including feelings of "rush" and "high" and drug liking. Nicotine also induced a dose-dependent increase in neuronal activity in a distributed system of brain regions, including the nucleus accumbens, amygdala, cingulate, and frontal lobes. Activation in these structures is consistent with nicotine's behavior-arousing and behavior-reinforcing properties in humans. CONCLUSIONS: The identified brain regions have been previously shown to participate in the reinforcing, mood-elevating, and cognitive properties of other abused drugs such as cocaine, amphetamine, and opiates, suggesting that nicotine acts similarly in the human brain to produce its reinforcing and dependence properties.

Categorization of types of medical/psychiatry units based on level of acuity.

Medical/psychiatry units can be categorized by the level of acuity of medical and psychiatric illness. Type I units are categorized as those that primarily provide psychiatric care with a low level of medical acuity. Type II units include general medicine or medical subspecialty units that are associated with a psychiatric liaison service and provide low levels of psychiatric care to those admitted to the general medical setting. Type III and Type IV units are characterized by a true departure from the current ward settings and care for patients who have concurrent and more severe medical and psychiatric problems in a unified setting. Both of these units require special physical changes in the ward structure, additional nurse training, and coordinated physician coverage to function effectively.

Quality assurance in a setting designed to care for patients with combined medical and psychiatric disease.

In an attempt to address the needs of patients with combined medical and psychiatric illness, a variety of clinical centers are now creating medical/psychiatry units. These units differ widely in their clinical capabilities, yet no adequate delineation of safeguards regarding quality of care currently exists. This article discusses minimum quality guidelines for four types of medical/psychiatry units that are based on the level of acuity of patients' medical and psychiatric disease.

A profile of academic medical-psychiatric units.

Medical-psychiatric inpatient programs are a relatively recent phenomenon. Although interest in these programs seems widespread, they are still found primarily at academic medical centers. The authors surveyed 11 such academic units. Variations found between their patient populations, milieu, and organization suggest that these programs, in general, are still in an early stage of evolution. It is hoped that these data will provide a descriptive base of how these programs have developed.

Length of stay on a psychiatry-medicine unit.

To assess the efficiency of a medical-psychiatric unit over 3 years, several studies were carried out on one combined psychiatry-medicine unit. On the Behavior Evaluation and Treatment Unit of the Medical College of Wisconsin, Division of General Hospital Psychiatry, average length of stay was calculated in successive cohorts of 28-31 consecutive patients (total 358 patients). Medical-surgical and psychiatric diagnoses were compared over a 2 1/2-year span; psychiatry diagnoses were compared to those on other units; and acuity of illness was measured comparatively by various methods. Length of stay decreased from more than 20 to less than 15 days. This effect did not appear to be directly related to diagnostic changes. Only minor increases in range of psychiatric diagnostic categories and changes in proportion of certain disorders were found. The acuity level was descriptively intermediate between that of a general medicine and that of a general psychiatry unit. Factors that could be related historically to these findings were discussed.

Treatment in combined medical psychiatry units: an integrative model.

Approximately 14 medical psychiatry units have opened over the last 15 years due to the recognition of the frequent concurrence of medical and psychiatric illnesses. This article discusses the clinical problems encountered when medical care and psychiatric care are integrated and their impact on medical and nursing staff. Group therapy programs on medical psychiatry units may enhance psychiatric treatment and help maintain a psychiatric focus by both patients and staff, despite the patients' significant medical problems. Medical psychiatric units must adopt an integrative model of care that includes all disciplines involved on the units if they are to meet their goal of providing effective medical and psychiatric care.

The role of empathy in medical students' choice of specialty.

The role of empathy in medical students' postgraduate training interest was studied. The level of empathy, as measured by the Hogan Empathy Scale, was not found to be a discriminating factor in career selection. Students interested in psychiatry had empathy levels similar to other groups of students. Although empathy has been suggested as a possible discriminating variable among medical school candidates, individuals with high and low empathy scores were found to be interested in every field of practice. Further studies are needed before measurement of empathy is used in the selection process for medical school admission.

Neuroleptic malignant syndrome: physiological and laboratory findings in a series of nine cases.

A series of nine cases of neuroleptic malignant syndrome (NMS) are presented with peak measures of autonomic dysfunction and laboratory findings. Urine abnormalities, consisting of proteinuria, casts, or cells, were an associated finding in these cases. Severe hypophosphatemia was present in two patients. Relative dehydration before the onset of the syndrome in eight of the nine patients supports the suggestion that it is a risk factor for the development of NMS. The withdrawal of dopamine agonists was also seen as a trigger for NMS. Autonomic instability and muscular rigidity occurred separately in some cases. Creatine phosphokinase elevation and fever did not necessarily parallel the duration or the degree of muscular rigidity, and this finding supports the idea of a central cause for the symptoms. A systematic approach is presented for the evaluation and treatment of NMS. Observations implicate central dopaminergic mechanisms in the regulation of autonomic functioning and the maintenance of peripheral muscle membrane stability.

CT, magnetic resonance imaging, and SPECT iodine-123 iodoamphetamine imaging of a patient with progressive cognitive deterioration.

A case of progressive cognitive deterioration is presented in which I-123 iodoamphetamine SPECT brain imaging was of value in confirming the clinical diagnosis of Alzheimer's disease.