Focal brain dysfunction in a 41-year old man with familial alternating hemiplegia.

The acute pathophysiologic changes during hemiplegic spells and the long-term outcome of alternating hemiplegia remain obscure. In a 41-year-old male with familial alternating hemiplegia we found an increase in right frontal cerebral blood flow 3 h into a 5-h left hemiplegic episode. A repeat high-resolution brain SPECT study performed 26 h after the resolution of the left hemiplegia revealed normalization of the frontal blood flow accompanied by hyperperfusion in the right parietal lobe. An interictal SPECT scan several weeks later showed no asymmetries. Head CT and MRI scans were negative. Neuropsychologic assessment and neurologic examination revealed evidence of a diffuse disorder which predominantly involved the right hemisphere. To our knowledge, there are no previous correlative studies of serial high-resolution brain SPECT with MRI, or of detailed neuropsychologic assessment, in adult patients with such an advanced course of alternating hemiplegia of childhood.

Relief of sleep apnea by revision of the adult upper airway. A review of clinical experience.

Surgical revision of the upper airway for obstructive sleep apnea has repeatedly improved subjective more than objective laboratory outcome measures. To examine this disparity, we obtained subjective sleepiness questionnaire scores, Continuous Performance test, and polysomnography (PSG) in 40 patients with mild to moderate obstructive sleep apnea (mean apnea index, 33.9; mean minimum oxygen saturation during sleep, 75.4%). Continuous Performance test confirmed abnormal daytime sleepiness and correlated with minimum oxygen saturation and number of transitions between stages. Postoperatively, questionnaire scores fell a mean of 62%, indicating a marked improvement in subjective sleepiness. Changes in questionnaire score correlated with changes in minimum oxygen saturation. Mean PSG indexes showed no change. Individual patients without PSG improvement reported long-term improvement in daytime functioning, as confirmed by family members. These results suggest that measures in addition to PSG, including patient subjective response, would more fully characterize the outcome of revision of the upper airway for sleep apnea.

Mixed organic brain syndrome as a manifestation of systemic mastocytosis.

Systemic mastocytosis is a disease characterized by an excessive accumulation of mast cells, and associated with skin lesions, flushing, diarrhea, tachycardia, and psychiatric manifestations. In order to define more clearly the psychiatric manifestations, ten patients with this disorder underwent unstructured psychiatric interviews and a battery of psychologic testing. Both revealed a pattern of cognitive and affective changes in the majority of these patients, best categorized as an atypical or mixed organic brain syndrome. The cognitive changes consisted of diminished attention and memory, and the affective changes of anger, irritability, and, to a lesser extent, depression. These manifestations fluctuated with the level of disease activity, and appeared in some cases to respond to histamine antagonists and disodium cromoglycate, medications used to control the excessive mast cell activity. It is important for psychiatrists to be aware that mental status changes can represent psychiatric manifestations of mastocytosis, a readily treatable medical disorder.

Controlled comparison of hemodialysis and peritoneal dialysis: Veterans Administration multicenter study.

We measured mortality and morbidity among 114 patients assigned randomly to home hemodialysis (HD) and home intermittent peritoneal dialysis (IPD). Data were collected during the time of home training and for 12 months after initiation of home dialysis. Training time was shorter for the IPD than for the HD patients (P less than 0.001) with median time 1.8 months for IPD and 3.9 months for HD. Switching to the alternative mode of treatment was more frequent for the IPD group (29/59 vs. 5/55, P less than 0.001). Survival time was not different, perhaps because of the modality change. More IPD patients were hospitalized in the first 6 months (20 for IPD vs. 9 for HD, P = 0.02), but they had fewer troublesome cardiovascular events in the first year (0 vs. 12, P less than 0.001). The HD patients maintained better nutritional status as reflected in body weight and arm muscle circumference and possibly in urea appearance rate. Thus, these data suggest that for most patients, IPD is a less satisfactory form of therapy than HD, but certain advantages of IPD did emerge. Applications of this information to the currently more popular mode of CAPD await further study.

The psychosocial impact of systemic lupus erythematosus and rheumatoid arthritis.

Seventy-six ambulatory patients with systemic lupus erythematosus and a comparison group of 23 ambulatory patients with rheumatoid arthritis were given a structured interview and standard psychological tests, including the Minnesota Multiphasic Personality Inventory, to determine the psychosocial impact of the illness. Both groups had significantly elevated scores on 3 Minnesota Multiphasic Personality Inventory scales: Hypochondriasis, Depression, and Hysteria. Psychological difficulties are an integral part of systemic lupus erythematosus and are as common as most other manifestations. The implications for clinical practice are discussed.

Unrecognized organic mental disorders in survivors of cardiac arrest.

Long-term survivors of cardiac arrest may suffer from mild cerebral impairment manifested primarily by personality changes and behavioral symptoms that can be mistaken for emotional responses to illness. The authors report six cases that illustrate the clinical problem of differentiating depression from organic brain dysfunction in this population. The diagnosis is facilitated by observation over time and by information from the spouse on baseline and current function. Chronicity, dysinhibition, apathy, and disturbances of judgment and insight indicate cerebral dysfunction. The accurate diagnosis of cerebral impairment after cardiac arrest is essential to the rehabilitation process.

Well-being of cancer survivors.

One hundred and four cancer survivors 3 years past their last cancer treatment reported a significantly lower sense of self-control and more general health worries than a matched sample of healthy controls. The two groups did not differ on variables of anxiety, depression, positive well being, and vitality or on two composite scores of mental and general well-being. The well-being scores of the survivors from three geographically distinct cancer centers revealed no significant differences among centers on the composite or any of the individual subscores. Sociodemographic and treatment variables revealed only marriage and no change in job were significantly related to the amount of general well-being experienced.

Acute psychological disturbances preceding life-threatening ventricular arrhythmias.

To investigate the prevalence of acute psychological disturbances during the 24 hours preceding life-threatening ventricular arrhythmias, we studied the mental states and psychological experiences preceding arrhythmic episodes in 117 patients who were referred for antiarrhythmic management. Sixty-two had survived cardiac arrest and 55 suffered symptomatic ventricular tachycardia. Twenty-five patients were experiencing acute emotional disturbances during the 24 hours preceding the arrhythmias. Eighteen had two or more episodes associated with psychological disturbances. These 25 patients were distinguished from the rest of the series in having generally less severe structural heart disease.

Development of brief measures of psychological adjustment to medical illness applied to cancer patients.

The interrater reliability and validity of brief interview rated measures of psychosocial adjustment were examined in four sequential studies. A total of 25 videotaped interviews with cancer patients were rated by 105 social workers, nurses, physicians, and specialists in psychosocial oncology. The Rating of Psychosocial Function (RPF), Coping Adequacy Rating (CAR), and Global Adjustment to Illness Scale (GAIS) were used by various rating groups with an indication of interrater agreement. Agreement on ratings was not influenced by the length of interview (15 vs. 30 minutes) but appeared to the affected by the structure of the interview and profession of the raters. All three instruments showed a measure of matching with clinical impressions in addition to demonstrating a measure of both convergent and divergent construct validation. The GAIS was chosen as most adequately reflecting their clinical impression by a majority of raters. With a degree of training, any of the three instruments could be used to assess psychosocial adjustment with some measure of confidence in the validity of the rating.

Psychophysiologic factors in sudden cardiac death.

Sudden cardiac death due to ventricular fibrillation is the leading cause of fatality in the industrially developed world. A considerable body of evidence indicates that the higher nervous system modifies electrical activity of the heart and may trigger sudden death. The evidence for increased risk for ventricular fibrillation due to psychophysiologic factors is supported predominantly by animal studies, but increasing evidence is forthcoming from human studies. The involvement of psychiatrists, psychologists, and cardiologists in a multidisciplinary approach to managing patients at risk for sudden death from ventricular fibrillation is yielding significant insights and prolonging their lives.

Portacaval diversion for severe hypercholesterolemia. Report of a case with measurements of glucose tolerance, insulin, and glucagon levels.

An end-to-side portacaval shunt was performed in a patient with severe coronary arteriosclerosis and type IIa hypercholesterolemia. By one year postoperatively there was a decrease of serum cholesterol concentration of more than 40%. No adverse side effects were noted. Intravenous and oral glucose tolerance tests were performed and were within normal range preoperatively and postoperatively. However, preoperatively, during the oral test, the serum insulin levels exceeded the normal range. In addition, glucagon levels revealed less tendency to suppression during the preoperative oral tests. Psychological testing revealed no abnormalitites, and serum ammonia levels were only slightly elevated.

An unusual adverse reaction to self-medication with prednisone: an irrational crime during a fugue-state.

During five years of self-medication with Prednisone, a forty-one-year old asthmatic businessman experienced periods of euphoria, psychomotor hyperactivity, and poor judgement; a period of depression and anxiety during temporary steroid withdrawal; and finally, with resumption of Prednisone, episodes of grandiosity and bizarre fugue-like behavior, with adoption of a second identity and culminating in an irrational crime. Steroids were then withdrawn, and the patient resumed his premorbid personality, but had amnesia for much of his previous behavior. The literature on hysterical fugues and corticosteroid-induced mental disturbance is reviewed. The patient's reactions are analyzed in terms of his premorbid neurotic conflicts, the psychological stresses acting upon him, and the effects of Prednisone on his central nervous system.

A case of prolonged, reversible dementia associated with abuse of electroconvulsive therapy.

Standards for the use of electroconvulsive therapy (ECT) are being considered in Massachusetts. While the relative safety of ECT is sometimes used to justify its extensive use, ECT is abused in some cases, causing prolonged deficits in sensorium. A case of an ECT-induced, prolonged, reversible dementia is presented as an example of present abuses and the need for standards.