Psychiatric and behavioral problems.

In an emergency setting, many neurologic conditions present with psychiatric and behavioral symptoms. These symptoms may either be the first manifestation of the neurologic illness or a later occurrence in the progression of the disease. It is important for clinicians evaluating patients with psychiatric symptoms to identify the signs indicating associated neurologic illness and to have strategies for managing the acute, potentially dangerous, neuropsychiatric manifestations of the disease. This article addresses emergency evaluation and management of depression, anxiety, psychosis, mania, suicide attempts, neuroleptic malignant syndrome and other hypermetabolic and amnestic syndromes, somatoform disorders, aggression, and legal issues, such as capacity to accept or refuse treatment.

Adult headbanging: sleep studies and treatment.

Headbanging is a rhythmic movement disorder (RMD) along with headrolling, bodyrocking and bodyrolling. The International Classification of Sleep Disorders defines RMD as a group of stereotyped, repetitive movements involving large muscles, usually of the head and neck, that typically occur immediately prior to sleep onset and are sustained into light sleep. The average onset is 9 months, and by 10 years of age the majority of subjects no longer complain of headbanging. If it continues, it is usually associated with mental retardation of autism. Headbanging is said to occur during presleep drowsiness or early non-rapid eye movement sleep. Often there is no need for treatment other than reassurance. Behavior modification has had little success. Benzodiazepines (such as oxazepam and diazepam) and tricyclic antidepressants have been used with variable success. We present two cases of headbanging with polysomnographic findings and treatment. The patients are two healthy adult males. They both experienced significant daytime somnolence and repeatedly wakened their partners. Only one of our patients had recorded head movements during his overnight sleep study. There was evidence of headbanging during stage 1 and stage 2 sleep but also during slow wave sleep. Headbanging was recorded during 14% of the epochs. Both patients responded to treatment with clonazepam (at a dose of 1.0 mg nightly) with decreased frequency and severity of headbanging. Although headbanging is most common in childhood, there may be significant number of cases that persist into adulthood. To our knowledge, this is the first report of the treatment of headbanging with clonazepam. Both patients benefited from this treatment.

Miliary tuberculosis in children: a review of 94 cases.

This is a retrospective review of the clinical, radiologic and laboratory features of 94 cases of childhood miliary tuberculosis seen during a 5-year period, 1985 to 1989. A history of Bacillus Calmette-Guérin vaccination was documented in 88% of children. The median age at presentation was 10.5 months, 52% of cases occurring in those younger than 1 year. The presenting symptoms were nonspecific: cough (72%); fever (61%); loss of appetite and weight (40%); and diarrhea and vomiting (33%). The main presenting signs were hepatomegaly (82%), splenomegaly (54%), lymphadenopathy (46%) and pyrexia (39%). Most of the patients were malnourished and anergic. Meningitis occurred in 19% of patients and this was the only significant risk factor identified for mortality, the overall case fatality rate being 14%. The diagnosis in the vast majority was made on the clinical presentation supported by a classic miliary pattern on chest roentgenogram (91% of cases). Mycobacterium tuberculosis was cultured in 33% of cases. In addition a review of hospital admissions from 1981 to 1989 revealed that annually miliary tuberculosis in children and adults accounted for 8.3 and 1.3%, respectively, of all tuberculosis admissions. This study confirms that miliary tuberculosis is a relatively common complication of tuberculosis in young children.

Minicolumn detection methods for aflatoxin in raw peanuts: collaborative study.

The Holaday-Velasco method and a modified Holaday method have been compared. The former method combines the speed and simplicity of the Holaday extraction and cleanup with the sensitivity of the minicolumn originally described by Velasco. The combination method has been approved by the AOAC and the AACC for determining aflatoxin in corn. The Holaday method was modified by substituting toluene for benzene in the solvent partition, and methylene chloride for chloroform in the minicolumn development to eliminate use of hazardous solvents. The neutral alumina in the Holaday minicolumn was changed from activity V to activity III to provide a more stable column. At aflatoxin levels in raw peanuts of 13-20 ng/g, the presence of aflatoxin was missed by the modified Holaday method in 4 analyses (3 laboratories) of 42 reported. There were no misses in this contamination range by the Holaday-Velasco method. There were no misses by either method with samples containing greater than 20 ng total aflatoxins/g. Analysis of uncontaminated raw peanuts by the modified Holaday method resulted in 2 false positives of 14 reports; the Holaday-Velasco method produced no false positive reports from 15 analyses of uncontaminated peanuts. The Holaday-Velasco method was adopted official first action for peanuts.

Exstrophy of the bladder: long-term results of bilateral posterior iliac osteotomies and two-stage anatomic repair.

One hundred cases of exstrophy of the bladder treated with bilateral posterior iliac osteotomies to facilitate anterior closure of the pelvis and soft tissues were reviewed. Sixty-nine cases followed 5 to 18 years were evaluated in terms of: success of anterior closure (95%); degree of urinary continence (45% with near normal continence); incidence of chronic urinary tract infection, dilation of upper urinary tract and need for ileal diversion (30%); the effect of bony reconstruction on hip and pelvic development. Modifications of the technique of pelvic stabilization anteriorly and a previously unreported complication of asymmetrical pelvic closure are presented. Closure of the bony pelvis appears to increase the success of repair of both in terms of soft-tissue closure and attainment of urinary continence. Follow-up examinations of the patients throughtout the growing years with special attention to possible development of pelvic obliquity or scoliosis are important.