Prescribed and self-medication use increase delays in diagnosis of tuberculosis in the country of Georgia.

SETTING: Georgia has a high burden of tuberculosis (TB), including multidrug-resistant TB. Enhancing early diagnosis of TB is a priority to reduce transmission. OBJECTIVE: To quantify delays in TB diagnosis and identify risk factors for delay in the country of Georgia. DESIGN: In a cross-sectional study, persons with newly diagnosed, culture-confirmed pulmonary TB were interviewed within 2 months of diagnosis and medical and laboratory records were abstracted. RESULTS: Among 247 persons enrolled, the mean and median total TB diagnostic delay was respectively 89.9 and 59.5 days. The mean and median patient delay was 56.2 and 23.5 days, while health care system delay was 33.7 and 14.0 days. In multivariable analysis, receipt of a medication prior to TB diagnosis was associated with increased overall diagnostic delay (adjusted odds ratio [aOR] 2.28, 95%CI 1.09-4.79); antibiotic use prior to diagnosis increased the risk of prolonged health care delay (aOR 4.16, 95%CI 1.97-8.79). TB cases who had increased patient-related diagnostic delay were less likely to have prolonged health care diagnostic delay (aOR 0.38, 95%CI 0.19-0.74). CONCLUSION: Prolonged delays in detecting TB are common in Georgia. Interventions addressing the misuse of antibiotics and targeting groups at risk for prolonged delay are warranted to reduce diagnostic delays and enhance TB control.

Unenhanced spiral CT for the assessment of renal colic. How does limiting the referral base affect the discovery of additional findings not related to urinary tract calculi?

The value of unenhanced spiral CT (UESCT) for investigating acute flank pain suggestive of urinary tract calculi is increasingly appreciated in the last few years. Recent studies have identified the advantages of UESCT in recognizing alternative findings within or outside the urinary tract. We sought to determine how narrowing the referral base for the UESCT would affect the discovery of potentially significant alternative findings in patients with acute flank pain suggestive of renal colic. Between January 1999 and December 1999, 425 patients, 271 (63.8%) men and 154 (36.2%) women who were 1-90 years old (mean 45.7 years old) with acute flank pain were studied with UESCT. CT studies were solely ordered by urologists, and only patients with intractable renal colic or patients that returned more than once to the emergency room with the complaint of acute flank pain were studied. A calculus within the ureter was diagnostic of an obstructive stone. Any other abnormality within the abdomen and pelvis was reported. A ureteral calculus was detected on 251 (59%) CT scans. Nineteen (4.5%) CT scans were consistent with recent excretion of a stone. In 112 (26.3%) CT scans, the cause for the patient's acute flank pain could not be explained. Forty-three (10.1%) alternative significant diagnoses that explain the patient's complaints were found. Nineteen (44%) were findings related to the urinary tract, and 24 (56%) were not related to the urinary tract. Ninety-seven (22.3%) additional findings not significant to the patient's current complaint were also reported. Even when narrowing the indications for the UESCT, about 10% of significant alternative findings to urinary stones were encountered. The variety of diagnoses found unexpectedly on the UESCT that alter a patient's management demonstrates the pivotal role of UESCT in triaging these patients rapidly towards optimal therapy. The UESCT can be used as a useful screening tool, sometimes revealing the exact pathology and sometimes directing the radiologist to the modality by which to continue.

Absence of neuropsychologic deficits in patients receiving long-term treatment with alprazolam-XR for panic disorder.

Studies to date on the effects of benzodiazepines on neuropsychologic function have yielded conflicting data with respect to the type, severity, and duration of deficits that may be induced by these agents. As part of a placebo-controlled trial of alprazolam-XR (extended release) administered in combination with cognitive-behavioral therapy in patients with panic disorder, a battery of tests was used to measure neuropsychologic function. Thirty-eight outpatients were randomly assigned to receive either alprazolam-XR or placebo. Dosages were titrated up so that the alprazolam group (N = 18) received a mean dose of 4 mg/day (reduced in two patients because of sedative side effects). Neuropsychologic function after 6 weeks of therapy at the target dosage was compared with baseline assessments in each group. Both groups showed a statistically significant improvement from baseline to repeated assessments on measures of attention, executive functioning, psychomotor speed, and visual memory (p < 0.001); these gains were attributed to a practice effect. No significant changes were noted in measures of learning, verbal memory, or reaction time, and neither group showed any deterioration from baseline to retesting in any aspect of neuropsychologic function. These findings call into question the assumption that long-term benzodiazepine therapy produces significant neuropsychologic deficit in patients with diagnosed anxiety disorders.

ABCR expression in foveal cone photoreceptors and its role in Stargardt macular dystrophy.

Mutations in the gene encoding ABCR are responsible for Stargardt macular dystrophy. Here we show by immunofluorescence microscopy and western-blot analysis that ABCR is present in foveal and peripheral cone, as well as rod, photoreceptors. Our results suggest that the loss in central vision experienced by Stargardt patients arises directly from ABCR-mediated foveal cone degeneration.

Quality of well being in panic disorder: the assessment of psychiatric and general disability.

BACKGROUND: Panic disorder is a common and debilitating anxiety disorder which significantly disrupts the lives of patients and their family members. Recent epidemiological studies and analyses of data from clinical trials suggest that patients with panic disorder suffer significant work and social dysfunction. The authors hypothesized that this dysfunction could be characterized using both a well-validated, generalized scale of functioning and a specifically designed scale for assessing function in psychiatric patients and that these findings would correlate with symptomatology. METHOD: Fifty-six patients with panic disorder were characterized using the Sheehan Disability Scale, the Anxiety Sensitivity Index, and the Spielberger State Trait Anxiety Scale. Measures of health related quality of life from the Quality of Well Being Scale were compared with ratings for matched, historical, and population controls. RESULTS: Patients with panic disorder lost 39 quality-adjusted days for each year that they lived with the disorder. This decrease in quality of life is similar to what is observed in patients with non-insulin dependent diabetes. Diminished quality of life is correlated with the number of panic attacks, state anxiety, and depressive symptoms. These patients also demonstrated significant dysfunction in Sheehan total disability and subscale scores, including work-related functioning. CONCLUSIONS: This study demonstrates that the specific disabilities inherent in panic disorder can be linked to declines in quality of life as measured by the Quality of Well Being Scale and by measures of work-related dysfunction. Such an association between disease specific measures and a generalized measure of health related quality of life may offer clinicians a new tool to understand panic disorder and to conceptualize it within the broader context of disease and disability.

Distribution of cerebral flow using retrograde versus antegrade cerebral perfusion.

BACKGROUND: This study compared flow to the brain with retrograde and antegrade cerebral perfusion during circulatory arrest. METHODS: Twenty-four rabbits were injected with 5 mCi of technetium-99 macroaggregated albumin, a tracer trapped in the capillaries. Group I (n = 6) were maintained normothermic, and the tracer was injected into the ascending aorta. Group II (n = 6) were maintained normothermic, and underwent cannulation of the superior vena cava (SVC), exsanguination through the aorta, and injection of the tracer into the SVC, which was proximally occluded. In group III (n = 6), the animal was cooled to 25 degrees C. The animal was exsanguinated through the aorta and tracer was injected into the ascending aorta. In group IV (n = 6), animals were cooled to 25 degrees C. The animal was exsanguinated through the ascending aorta and tracer was injected into the SVC. Three animals (group V) were exsanguinated through the ascending aorta and a retrograde venogram of the SVC was performed. Scintigraphy of groups I to IV was carried out on a digital gamma camera. Brain trapping of tracer was graded from 0 to 5, with 0 being no tracer in the brain and 5 being dominant tracer trapping in the brain. RESULTS: Tracer trapping in the brain showed group I, 3.67+/-0.82; group II, 0; group III, 4.67+/-0.41; group IV, 0.17+/-0.41 (p<0.0001). Retrograde venogram of the SVC showed flow into the cerebral veins. CONCLUSIONS: Retrograde flow through the SVC reaches the cerebral venous system. Flow arriving in retrograde fashion does not go through the capillary system.

A neuropsychological study of panic disorder: negative findings.

BACKGROUND: Gray (1982) proposed that the septo-hippocampal system, which plays an important role in learning and memory, may partially mediate anxiety. Thus, patients with anxiety disorders may manifest neurocognitive performance deficits. We hypothesized that patients with panic disorder would demonstrate learning and memory deficits relative to normal comparison subjects. METHOD: Comprehensive neuropsychological batteries were administered to 69 panic disorder subjects and 19 normal volunteers. RESULTS: There were no significant group differences in any neuropsychological performance domain including learning, memory, attention, visuospatial functioning, and psychomotor speed. Multiple regression conducted to evaluate the contribution of clinical symptoms to neuropsychological impairment within the panic disorder sample revealed that anxiety severity did not affect neuropsychological test performance. LIMITATIONS: Most patients had mild or moderate, rather than severe, panic disorder. CONCLUSION: Neuropsychological dysfunction was not associated with panic disorder.

CT diagnosis of non-traumatic subarachnoid haemorrhage in patients with brain edema.

The aim of the study is to prove, retrospectively, that it is unlikely that the computerized tomography (CT) diagnosis of subarachnoid haemorrhage (SH) accompanies the CT diagnosis of generalized brain edema. A total of 100 comatose patients underwent CT of the brain. Of this number, 42 underwent an enhanced CT scan. In 26 patients, lumbar puncture was also performed. A control group of ten patients diagnosed with headache and having a normal CT scan underwent NECT and ECT. Measurements of the white and gray matter density in Hounsfield units (HU) were performed in all 110 cases, including the controls. The brain tissue density and the difference between the densities of the white and gray matter were lower in the cases with brain edema than in the controls. The data values were statistically significant. Small cerebral ventricles, sulci and cisterns and small differences between white and gray matter measurements were observed in the CT scans of the brain edema cases. All 100 patients had CT diagnosis of brain edema and SH. There was no bloody or xanthochromic CSF in any of the 26 lumbar punctures performed. In the enhanced CT scans, there was poor or no filling of the lateral sinuses. The compression of the lateral sinuses by the edematous brain tissue most probably results in their stenosis or obstruction due to disturbed brain venous drainage which can mimic CT findings of SH.

Unilateral medial dislocation of the temporomandibular joint.

We present our experience of the rare condition of unilateral medial dislocation of the temporomandibular joint (TMJ) in 11 patients with head trauma who had received a direct lateral blow on the chin. The diagnosis was made by direct coronal CT of the TMJ performed from 6 h to 7 days following the injury. In 6 patients, subcondylar fracture of the ipsilateral mandibular ramus was also demonstrated. A second CT performed 11-16 months following the first one demonstrated pseudoarthrosis of the fractured ramus in these 6 patients. The second CT was identical to the first in the remaining 5 patients with pure dislocation of the condyle. All patients suffered from severe disability of the TMJ. The maximal vertical distance between the upper and lower incisors in patients with uncomplicated dislocation ranged between 8 and 12 mm. In cases with complicated medial condylar dislocation with fracture and pseudoarthrosis of the mandibular ramus, this distance ranged between 16 and 25 mm, probably because of additional movement in the area of the pseudoarthrosis. The maximal vertical distance between the incisors was compared with a control group of 20 normal adults who had values from 40 to 52 mm. Medial unilateral dislocation of the TMJ can appear in two forms: uncomplicated or complicated, with pseudoarthrosis of the ipsilateral mandibular ramus.

Placenta accreta. Additional sonographic observations.

Recent reports describe the antenatal sonographic diagnosis of placenta accreta based on failure to visualize a hypoechoic zone at the placental margin. This finding was confirmed in our series of seven cases. New observations in this series include prominent large or multiple placental venous lakes and periuterine vascularity in six of seven cases, and progressive thinning and disappearance of the retroplacental hypoechoic zone on sequential examinations in two of seven cases. Loss of normal venous flow pattern on Doppler interrogation of the peripheral placental margin also appeared to be of value in two patients. Histologic correlates for these findings are suggested on the basis of the primary histopathologic feature of placenta accreta: deficiency of the decidua basalis. Differential diagnostic considerations, including abdominal pregnancy and trophoblastic disease, also are discussed.

Dilated periportal lymphatics mimicking an anastomotic bile leak after liver transplantation.

Transhepatic cholangiography is commonly performed during postoperative evaluation of liver transplant patients. The authors describe a potential pitfall in the interpretation of these studies and illustrate that dilated interrupted lymphatics of the donor liver can mimic a periductal leak of contrast material.

The effect of restricting the indications for lumbosacral spine radiography in patients with acute back symptoms.

A prospective study was performed to evaluate the effect of using a special requisition form on the utilization of lumbosacral spine radiography for patients presenting in the emergency room with acute lower back complaints. Over a 1-year period, emergency room house officers were encouraged to complete a special form that listed only three acceptable indications for lumbosacral spine radiographs: history of trauma, evidence of focal neurologic abnormality, and "other." Neurologic abnormalities included hypesthesia, hyperesthesia or anesthesia of lumbar or sacral dermatomes, weakness or hyporeflexia of the lower extremities, and bladder or bowel incontinence. If the indication "other" was chosen, radiographs were done only if the form contained both a one- to two-sentence history and the signed approval of a supervising attending physician. The number and results of lumbosacral spine examinations were compared with those from the previous year, which served as a control. In the control year 1443 examinations were performed, and in the experimental year only 759 were done (a decrease of 47%). The percentage of patients with vertebral fractures increased from 5.1% to 5.8% in the experimental year if only the detection of new fractures was considered positive, and from 9.1% to 13.4% if the detection of fractures of all ages was regarded as significant. The use of the special requisition form appears to be a simple and effective means of reducing unnecessary lumbosacral radiography in the emergency room setting.

The schizophrenic diathesis and the kibbutz.

In this article, the National Institute of Mental Health (NIMH) "Israeli High Risk Study," which extended over two decades and compared the relative effects of kibbutz and city environments on the diathesis of schizophrenia, is critically examined. Comparison data on personality and cognitive functions of groups of 11- to 16-year-olds and adults are reviewed in the light of previously published material. The apparent shifts in level of adjustment of kibbutz and city subjects, as well as the allegedly greater incidence of pathology in the kibbutz index group, are questioned on methodological grounds.

The Sentence Completion Method--recent research.

The present article reviews recent work with the Sentence Completion Method (SCM) and examines the method's effectiveness as an assessment instrument. Studies in which the SCM was employed in testing hypotheses concerning personality and its development, as well as reports that deal with maladaptive functioning and psychopathology are covered. Also reviewed is some work that investigates the nature of the method itself. The overall conclusion is that the SCM is flexible, readily adaptable in various research and clinical settings, and to be recommended for continuing use and application.