Occipital neuralgias: clinical recognition of a complicated headache. A case series and literature review.

The objective of this study was to assist clinicians in the diagnosis of the occipital neuralgia syndrome by describing its clinical characteristics. Bibliographies and clinical descriptions of occipital neuralgia syndrome were identified through a review of literature published between 1966 and 1993. A prospective case series was performed by the authors in a university emergency department during a 1-year period. Patients with unilateral aching pain of the head, coupled with pain in the distribution of the occipital nerve, Tinel's sign, and relief of pain after local anesthetic injection, were included. Patients rated pain relief on a 10-point scale. Twelve patients met the criteria for occipital neuralgia and were included in the study. All patients reported at least 80% decrease of pain after injection, and 42% had complete relief. Clinical features, other than headache, that were common in patients included tinnitus in 33%; scalp paresthesia, 33%; nausea, 42%; dizziness, 50%; and visual disturbances, 67%. Occipital neuralgia is a benign extracranial cause of headache, and it may be confused with other more serious headache syndromes. Recognition depends on an understanding of the symptoms along with a careful history and physical examination. Local anesthetic injections produce significant relief of the headaches and can aid in the diagnosis of the syndrome.

Basilar migraine.

Basilar migraine is a complicated headache which the International Headache Society describes as 'migraine with aura symptoms clearly originating from the brainstem or from both occipital lobes'. For years this headache was thought to originate from a transient disturbance in the vertebrobasilar circulation, but more recent studies suggest that a central neuronal disorder may be the source of migraine. Basilar migraines may have certain symptoms which are similar to other neurologic, vascular, psychiatric and metabolic diseases, yet there are specific criteria which can help differentiate it from other diagnoses. It is characterized by a throbbing occipital headache which may be preceded by an aura. The unusual symptoms of basilar migraine, which may precede and continue throughout the duration of the headache and even after it, include bilateral visual symptoms, altered mental status, vertigo, gait ataxia, bilateral paresthesia, bilateral paralysis and dysarthria. We describe a 29-year-old black female whose husband brought her to the emergency department complaining of confusion, headache, and left-sided weakness for 2 h prior to arrival.

Benign paradoxical vocal cord adduction presenting as acute stridor.

We present a case of benign paradoxical vocal cord adduction' presenting to the emergency department as acute stridor. This patient received direct laryngoscopy at initial presentation documenting inspiratory vocal cord adduction. The syndrome is not well known to emergency physicians and, because it often mimics life-threatening airway compromise, prompt recognition of the benign nature of this syndrome may avert more aggressive airway interventions such as beta agonists, steroids, endotracheal intubation and tracheostomy. Successful treatment has included relaxation, sedatives and speech therapy to abort the acute attack and prevent further recurrence. As direct flexible laryngoscopy is more readily available in the emergency department, goals for the future are more rapid diagnosis and appropriate treatment of this benign syndrome.

Stiff-man syndrome: case report.

Stiff-man syndrome is a rare neurologic disorder characterized by progressive, fluctuating muscle rigidity with painful muscle contractions affecting predominantly the back and proximal extremities. In the ED, the diagnosis can be easily overlooked and misdiagnosed as acute or chronic low back pain and muscle spasm. This syndrome is often associated with diabetes, autoimmune diseases, and cancer. This report describes an illustrative case of a 39-year-old woman who presented to the ED with a two-year history of right leg spasms and low back pain that had become so severe in the preceding two days that she was unable to ambulate. Clues to the patient's proper diagnosis coincide with the diagnostic criteria for stiff-man syndrome: the presence of a slowly progressive stiffness of the axial muscles and proximal limb muscles, making ambulation difficult; hyperlordosis of the lumbar spine; episodic spasms precipitated by jarring or sudden movement; a normal intellectual, sensory, and motor examination when not in spasm; and a marked amelioration of symptoms with the IV administration of diazepam. High-dose oral diazepam is the maintenance drug of choice.

Psychiatric distress during stages of the heart transplant protocol.

Psychiatric observations are reported on 101 heart transplant candidates (40 of whom had transplantations). Emotional responses were recorded during the evaluation, during the waiting period, perioperatively, at biopsy, during rejection episodes, and before and after discharge. Those phenomena, with the exception of behavioral management problems, were unrelated to initial psychiatric diagnoses; the diagnoses often reflected emotional reaction to cardiac illness. Most distress after evaluation appeared to be related to the protocol rather than to preexisting psychopathology. The stage of the protocol affected the nature of the reactions. Psychiatric assistance aided the adjustment process.

Receptor-mediated stimulation of taurocholate efflux from the rat hepatocyte and the ex vivo perfused rat liver.

The peptide hormone, arginine-vasopressin[( Arg8]vasopressin, AVP), stimulates efflux of the bile salts taurocholate and glycocholate from the rat hepatocyte in suspension via its association with the V1 receptor on the hepatic cell membrane. At a concentration ratio of 5:1 (antagonist to hormone), the V1 vasopressin antagonist, (dCH2)5Tyr(Me)AVP, inhibits the vasopressin induced efflux of taurocholate by approximately 82%, and of glycocholate, by approximately 85%. In contrast, the V2 antagonist (d(CH2)5[D-Ile2,Ala4]AVP, does not interfere with the stimulation of taurocholate and glycocholate efflux by vasopressin. In the isolated perfused rat liver, vasopressin (5 X 10(-10) M) causes an immediate increase of 55 +/- 12% over baseline in [14C]taurocholate secretion and a corresponding increase in bile flow. A more gradual and prolonged increase in [14C]taurocholate secretion, reflecting an increased biliary concentration of [14C]taurocholate, is observed beginning 6 min after vasopressin, reaching a plateau of 23 +/- 12% over baseline by 14 min and returning to baseline by 30 min. The mean rate of 14C secretion during the 30 min following administration of vasopressin (non-steady state) is increased by 14.3 +/- 6.4% over pre-infusion steady-state baseline (P less than 0.05). Prior administration of the V1 receptor antagonist d(CH2)5Tyr(Me)AVP attenuates these effects of vasopressin. The combination of these in vitro and in vivo findings suggest that vasopressin may play a role in regulating bile salt efflux. Furthermore, these studies in the isolated hepatocyte and the intact liver may provide a unique approach for defining biochemical changes associated with bile salt transport from the hepatic cell.

Psychiatric assessment of leg fracture patients: a pilot study.

Of 200 consecutively admitted leg fracture patients, 101 consented to be screened for psychopathology using the BSI and SMAST questionnaires. Probable cases of psychopathology were referred for diagnostic psychiatric evaluation. Of the participants, 80.2 percent were identified as possible psychiatric cases. Diagnostic evaluation revealed high prevalence of substance abuse (66.0%), depression (46.8%), and personality pathology (38.3%). Accident victims tended to be single young males. Accidents occurred mostly during leisure hours, and were often associated with alcohol use. Psychiatric assistance appears essential in the management of such patients. Psychiatrists need to be especially knowledgeable about chemical dependency, interpersonal issues and psychotherapy.

Psychopathology in heart transplant candidates.

Psychodiagnostic data are reported on 69 heart transplant candidates. Twenty-seven patients actually received a transplantation. A high prevalence of anxiety and depression appeared related to their desperate cardiac status. Distressful symptoms did not predict postoperative psychiatric complications. Reduced coping skills as reflected by diagnoses of personality disorders or organic mental impairment were associated with many behavioral problems capable of jeopardizing survival. Psychiatric input is necessary for, and was helpful in, the management of these patients.

Stimulation of taurocholate and glycocholate efflux from the rat hepatocyte by arginine vasopressin.

Vasopressin induces alterations in the transmembrane distribution of the bile salts taurocholate and glycocholate but not of cholate, chenodeoxycholate, or chenodeoxycholate derivatives in isolated rat hepatocytes in suspension. Studies were conducted to define the specific transport events modulated by vasopressin. Unidirectional uptake of cholate, taurocholate, and glycocholate, monitored within a 15-s time frame, is not altered by vasopressin. Km values for cholate, taurocholate, and glycocholate influx were found to be 57, 12, and 26 microM, respectively. Vmax values for influx of cholate, taurocholate, and glycocholate were 1.7, 1.8, and 2.4 nmol.mg protein-1.min-1, respectively. At half-maximal effective concentrations, arginine vasopressin increases unidirectional efflux of taurocholate by 34% (EC50 = 1.5 X 10(-9) M) and glycocholate by 17% (EC50 = 5 X 10(-9) M). In the presence of 0.05 microM arginine vasopressin, the apparent Km value for taurocholate efflux decreases from 1.57 mM (control) to 0.94 mM; for glycocholate, the apparent Km decreases from 5.19 mM (control) to 3.22 mM. Vasopressin does not significantly change the Vmax values for taurocholate and glycocholate efflux (0.40 and 1.05 nmol.mg protein-1.min-1, respectively). These studies suggest that modulation of bile salt efflux by vasopressin may be utilized to probe bile salt transport pathways in the rat hepatocyte.

Emotional adjustment to cardiac transplantation.

Emotional adjustment to cardiac transplantation is a phasic process. Each step is associated with a milestone in the transplantation protocol. The adjustment process is divided into seven distinct stages: 1) transplant proposal, 2) evaluation, 3) awaiting a donor organ, 4) perioperative period, 5) inhospital convalescence, 6) discharge, and 7) post-discharge adaptation. Patient adjustment to transplantation is influenced by the adaptive task of each stage in the procedure, personality factors, previous experience with illness, and social support. Patients need time to adjust to each stage. Do not pressure them into premature acceptance of transplantation. Verbalization of feelings should be encouraged, and adequate support ensured. Contact with already transplanted patients is helpful to surgical candidates. Psychiatric assistance can greatly aid in patient management and emotional adjustment.

Informed consent issues in the cardiac transplantation evaluation.

As consultation-liaison psychiatrists to a cardiac transplantation team, we have observed various informed consent issues that are particularly associated with evaluation for cardiac transplantation. We discuss complicating factors that relate to each component of informed consent and present the defense mechanism of denial as a barrier to making the decision to accept or refuse transplantation. Changes in the evaluation protocol could preclude existing impediments to provision of information and patient autonomy; however, certain intrapsychic issues must be recognized as ongoing clinical realities to be addressed as the doctrine of informed consent continues to evolve.

The tip of the iceberg: psychiatric consultations on an orthopedic service.

One hundred and one consecutively admitted orthopedic patients with leg fractures participated in a study assessing psychiatric morbidity using the BSI- and SMAST-questionnaires. Patients identified as probable cases of psychopathology were then psychiatrically evaluated to establish diagnoses. It was determined that about 70 percent of the sample met the criteria for psychiatric diagnoses, with substance abuse being the leading group of disorders. The psychiatric consultation-liaison and orthopedic services remained blind to the research activities and continued to refer patients for psychiatric consultation when clinically necessary. Only six (5.9%) of the patients also participating in the study were referred for clinical consultation, and these appeared to have very obvious symptoms or complaints. The large majority of emotional distress remained unnoticed.

Ambivalence in cardiac transplantation candidates.

During three and a half years of psychiatric liaison with a cardiac transplantation program, the authors evaluated and followed 101 transplantation candidates. Ten exhibited pronounced ambivalence toward cardiac transplantation. Ambivalence appears to be associated with three factors: difficulties facing the seriousness of the cardiac illness, fear of the actual operation, and quality of life-concerns. An essentially nonpathological response, ambivalence can produce significant psychiatric symptoms and management problems in transplant candidates. Its resolution can be facilitated by psychotherapy, appropriate medication, peer support, and patience. Some patients may need particular assistance in understanding that refusal of transplantation is an acceptable alternative.

Neuroleptic malignant syndrome as a possible postoperative complication: a case report.

Neuroleptic therapy for postoperative agitation in a mentally retarded schizophrenic patient is described. Clinical features consistent with neuroleptic malignant syndrome (NMS) developed. NMS is a dangerous, drug-induced complication of neuroleptic administrations that can be a differential diagnostic problem. Already often misdiagnosed, this syndrome is especially likely to be unrecognized in nonpsychiatric settings, and may occur postoperatively. Failure to recognize NMS may lead to reexposures to the offending agent, with potentially grave consequences.