Clinical features of pathological grief reaction in elderly patients.

The present study investigates elderly patients suffering from a pathological grief reaction to bereavement. The subjects were nine elderly inpatients with pathological grief reactions in the Department of Psychiatry in Fukuoka University Hospital between April 1991 and March 1995. Medical records of all patients were investigated retrospectively. The results were as follows: (i) all patients were female; (ii) the deceased were all husbands; (iii) most cases were sudden death; (iv) the period to onset was variable, from immediately after death to 10 years after death; (v) a delay of grief reactions was seen in many patients; (vi) the direct causes were often something other than bereavement, such as conflict with sisters, change of residence, bone fracture and daughter's malignant illness; (vii) although there was no significant difference, the ratio of those who began to live alone after bereavement was high; (viii) the number of children were insignificant; and (ix) many patients suffered the death of a parent in childhood. The paper presents observations on the results, and discusses the psychosocial factors of elderly patients with pathological grief reactions to bereavement.

Recent developments in American psychiatry and Dr. Melvin Sabshin's contributions to them.

A "Dialogue" session was set up during the seventh scientific meeting of the Pacific Rim College of Psychiatrists in 1995. The objective of this session was to clarify the opinions of great scholars on modern psychiatry and their contributions to its development. Participants discussed characteristics of psychiatry in various countries as well as the future of world psychiatry. The following article is the "dialogue" that occurred between Professor Nishizono and Dr. Melvin Sabshin.

Occurence of a sialylglycopeptide and free sialylglycans in hen's egg yolk.

Free sialylglycans (FSGs) and a sialylglycopeptide (SGP) as components of hen's egg yolk were found and their chemical structures were determined. SGP and FSGs were isolated from fresh egg yolk by treatment with phenol, gel filtration and successive chromatographies on columns of anion- and cation-exchangers. They were localized in the yolk plasma. The glycan moiety of SGP, which was liberated by PNGase digestion, was studied for the chemical structure by HPLC mapping with p-aminobenzoic ethylester-derivatization, sugar composition analysis, 1H nuclear magnetic resonance and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry and the glycomoiety was found to be an N-linked disialyl-biantennary glycan. The amino acid sequence of the peptide moiety of SGP was determined to consist of Lys-Val-Ala-Asn-Lys-Thr, the Asn of which is modified with the disialylglycan moiety. FSGs were determined to be two free disialyl-biantennary glycans whose reducing end was either Man beta1-4GlcNAc (FSG-I) or Man beta1-4GlcNAc beta1-4GlcNAc (FSG-II). Since the molar value of SGP present in one egg yolk (2.8 micromol) is comparable to those of well-known major yolk proteins, low density lipoprotein, lipovitellins and phosvitin, it can be considered that SGP is one of the major components in hen's egg yolk.

Distribution and characterization of rat immunoreactive proadrenomedullin N-terminal 20 peptide (PAMP) and the augmented cardiac PAMP in spontaneously hypertensive rat.

Proadrenomedullin N-terminal 20 peptide (PAMP) is a novel hypotensive peptide processed from an adrenomedullin precursor. In this study, high concentrations of immunoreactive PAMP (ir-PAMP) were detected in rat cardiac atrium and adrenal gland by the radioimmunoassay (RIA) for rat PAMP. The mean plasma concentration of rat ir-PAMP was 3.8 +/- 0.3 fmol/ml. Analysis in atrium, adrenal gland and plasma with high performance liquid chromatographies showed that most ir-PAMP emerged as one major peak at the position exactly identical to that of the authentic rat PAMP. We further investigated the tissue and plasma concentrations of rat ir-PAMP in spontaneously hypertensive rat (SHR) to elucidate the role of PAMP in hypertension. The ir-PAMP concentration in heart tissue of SHR was found to be increased compared with that of the control rat. Especially, the atrial concentration of ir-PAMP of SHR (5.66 +/- 0.78 fmol/mg wet tissue) was significantly higher than that of the control (3.29 +/- 0.22 fmol/mg wet tissue). Cardiac PAMP might have a role for the protection from systemic hypertension.

Distribution and characterization of immunoreactive rat adrenomedullin in tissue and plasma.

Adrenomedullin is a new bioactive peptide recently isolated from pheochromocytoma. We report on the rat adrenomedullin distribution and molecular forms in various tissues and plasma. Using a sensitive radioimmunoassay system for rat adrenomedullin, high concentrations of immunoreactive rat adrenomedullin were detected in adrenal gland, lung and cardiac atrium. In lung and atrium, the immunoreactivity concentration in rat was about 6-10 times higher than that in human. The mean plasma concentration of immunoreactive rat adrenomedullin was 3.60 +/- 0.34 fmol/ml (mean +/- S.D.). Analysis in adrenal gland, lung and atrium with reverse-phase and gel-filtration high-performance liquid chromatography showed that most immunoreactive rat adrenomedullin emerged as a single peak at a position exactly identical to that of the authentic rat adrenomedullin peptide, synthesized according to the sequence predicted from the cDNA.

Endoscopic ultrasonography using a 15/20 MHz probe in a direct contact technique: evaluation and application in esophageal and gastric varices.

Endoscopic ultrasonography (EUS) has been recently developed as a new diagnostic technique for portal hypertension. However, its conventional water-filled balloon technique is not suitable for the evaluation of esophageal varices, because the vessel lumen is compressed by the inflated balloon. Particularly for small varices, the vessel tends to collapse and is difficult to display. A miniature ultrasonic probe for use via the forceps channel in EUS has been developed and is expected to overcome this difficulty. Here we report the efficacy of this new probe in patients with esophago-gastric varices. Instead of using a water-filled balloon for an acoustic window, we displayed the EUS findings from the new probe in direct contact with gastrointestinal wall by removing air from the lumen under vacuum. Both conventional endoscopy and the new EUS were performed on 3 patients with esophageal varices. The transforceps-channel ultrasonic probe visualized grade 1 varices in addition to the larger varices, confirming this technique to be a useful method for assessing of esophageal varices. Moreover, this method does not require a specially designed endoscope for EUS, rather it can be employed in combination with conventional endoscopy. We conclude that this new technique is a preferred diagnostic technique, and it should become more widely accepted for routine clinical applications.

Ethical issues in psychotherapy.

The goal of psychotherapy is not only the dissolution of the symptoms, but also to attempt to bring about an improvement in adaptability and deepening the achievement of self-understanding. The nature of psychotherapy is based on the relationship between the therapist and patient. Such a goal and nature mean that some kinds of psychotherapy are beyond the medical model. In this paper ethical issues in psychotherapy are discussed as follows. 1) some complicated matters in informed-consent, 2) the hit or miss techniques of the poorly trained therapist, 3) the protection of privacy, 4) the sexual misconduct of therapists with patients, 5) special consideration for child-adolescent patients.

Portal hypertensive gastropathy in patients with cirrhosis.

Portal hypertensive gastropathy is a recently recognized important complication of cirrhosis. In the present study, the clinical features, portohepatic hemodynamics, and hepatic function were investigated in a series of 47 patients with cirrhosis. Mild gastropathy was found in 15 patients (32%) and severe gastropathy in 17 patients (36%). The presence of gastropathy seemed to be independent of age, sex, cause of cirrhosis, or grade of gastroesophageal varices. However, severe gastropathy was associated with an increase in portal venous pressure gradient (vs. control, P less than 0.01; vs. mild gastropathy, P less than 0.01), an increase in hepatic sinusoidal resistance (vs. control, P less than 0.01; vs. mild gastropathy, NS), and a decrease in hepatic blood flow (vs. control, P less than 0.01; vs. mild gastropathy, NS). In addition, patients with severe gastropathy had impaired metabolic activity of the liver, which was assessed by intrinsic clearance of indocyanine green (vs. control, P less than 0.01; vs. mild gastropathy, NS). These observations may have important therapeutic implications in patients with cirrhosis and portal hypertensive gastropathy.

Portohepatic pressures, hepatic function, and blood gases in the combination of nitroglycerin and vasopressin: search for additive effects in cirrhotic portal hypertension.

We studied the effects of the combination of nitroglycerin and vasopressin on portohepatic hemodynamics, hepatic function, and blood gases in nine patients with cirrhosis and portal hypertension. Vasopressin infusion at a dose of 0.4 U/min caused a significant fall in portal pressure, which is evaluated by portal venous pressure gradient (-34%, p less than 0.01), associated with a decrease in hepatic perfusion (-33%, p less than 0.01) and intrinsic clearance (-20%, p less than 0.01) after 30 min. The arterial oxygenation, however, was not modified (paO2; from 73 +/- 8 to 72 +/- 7 mm Hg, NS). Nitroglycerin infusion at a dose of 100 micrograms/min was then administered for 20 min. The addition of nitroglycerin produced a further reduction in free portal venous pressure (-12%, p less than 0.01), but this was not associated with a significant improvement in both hepatic perfusion (+16%, NS) and intrinsic clearance (-7%, NS). In addition, there was a significant fall in arterial oxygenation (paO2; from 72 +/- 7 to 59 +/- 5 mm Hg, p less than 0.01). We conclude that the addition of nitroglycerin to vasopressin has a beneficial effect on free portal venous pressure, but does not have hepatic benefit. Moreover, sufficient care must be taken, when treating portal hypertension with this combination, to avoid arterial hypoxemia.

Lack of hepatic benefit by oxygen inhalation during vasopressin infusion in patients with cirrhosis.

Vasopressin has been found to impair hepatic function in patients with cirrhosis. The aim of this study was to investigate whether oxygen inhalation could improve hepatic function during vasopressin infusion. Vasopressin (0.3 iu/min) was infused into eight patients with cirrhosis for 50 min. During the first 30 min they were ventilated by room air and for the following 20 min by oxygen (approximate 50% of FiO2). The extra oxygen inhalation caused a typical increase in arterial (+7%, P less than 0.01), portal venous (+8%, P less than 0.05), and hepatic venous (+9%, P less than 0.01) oxygen content. No effect was noted in arterio-hepatic venous and portal venous-hepatic venous oxygen content difference in comparison with the values after vasopressin alone. The hepatic perfusion remained unchanged. These results suggest that the extra oxygen did not increase hepatic oxygen uptake. Similarly, intrinsic clearance of indocyanine green did not improve. It is concluded that oxygen supplement in this setting has no hepatic benefit in patients with cirrhosis.

Collaborative multicenter field trial of the Draft of ICD-10 in Japan--interdiagnostician reliability and disagreement: a report from the WHO project on "field trials of ICD-10, Chapter V".

The Draft of "ICD-10, Chapter V, Clinical Descriptions and Diagnostic Guidelines" was tested in a multicenter field trial in Japan. We have previously reported good results in suitability, confidence and ease of diagnosis, and adequacy of descriptions of the Draft. In this paper, the interdiagnostician reliability of the Draft is reported. Among the two-character categories, "Schizophrenia, Schizotypal States and Delusional Disorders (F2)" (ICC = .80) and "Mood Disorders (F3)" (ICC = .80) proved reliable. "Neurotic, Stress-Related, and Somatoform Disorders (F4)" was less reliable (ICC = .65). The ICCs of the 17 major categories (three-character code) and the 21 subcategories (four-character code) were also calculated. The finding that in Japan subtyping schizophrenia with ICD-10 was more reliable than that made using DSM-III Diagnostic Criteria supports the need to use a descriptive version of ICD-10 as the basis for several versions serving different purposes. The nature of disagreements with unreliable categories was also investigated. The results are discussed with special reference to the changes in the final Draft of Chapter V, which contained a feedback of the results from field trials from all over the world.

Concordance rate between clinical and DIS diagnoses: a cross-cultural comparison.

Concordance rates between clinical and DIS-generated diagnoses were compared using data sets from Fukuoka University in Japan and Neuropsychiatric Hospital at the UCLA. An overall concordance rate of 35% between standard clinical diagnosis and DIS-Lifetime diagnosis was discovered in both samples. Next, concordance rates were analyzed by diagnostic category, and differential concordance rates among major diagnostic categories were found in both samples. The highest concordance rates were found in anxiety disorders and major depression. The lowest concordance rates were found in dysthymic disorder and schizophrenia. The Fukuoka sample contained more patients with anxiety disorders and major depression, while the UCLA sample has more patients diagnosed as dysthymic disorder and adjustment disorder. Future directions in cross-cultural psychiatric research are also suggested.

Follow-up study of camp marathon group psychotherapy for adolescents with emotional disturbances.

Every summer since 1972, the Department of Psychiatry at Fukuoka University has been holding the Camp Marathon Group Psychotherapy (MGP) for adolescents with emotional disturbances. This time we conducted a follow-up survey on 114 camp attendees from 1978 to 1985. Questionnaires were mailed out and we received 56 replies, that is a response rate of 49.1%. The average observation period of the follow-up was 4 years. The results were as follows: Thirty-six cases or 64.3% were making satisfactory progress at the time of the survey. Eight or 14.3% showed no change or showed worsening conditions. Seven or 12.5% cases developed into schizophrenia. Based on these results, we studied roughly what role MGP plays in the therapy of adolescents with emotional disturbances.

A case of spontaneous mesenteric hematoma and a review of 17 cases in Japan.

A 47 year-old male was admitted to Miyazaki Medical college Hospital for further evaluation of an abdominal mass in the left upper quadrant. Abdominal ultrasound (US) and abdominal computed tomography (CT) showed two cystic masses in the mesenterium, which were suspected to be hematomas, but were not related to the pancreas, kidney or spleen. Superior mesenteric artery angiography and gallium (GA)-scintigraphy showed no definite findings. The patient underwent laparotomy on a suspicion of mesenteric hematoma. Two 4 x 3 x 3 cm soft tumors were found in the small intestinal mesenterium. These masses were histopathologically hematomas and surrounded by thick collagenous granulation tissue. The patient had no recent history of abdominal trauma, taking drugs capable of producing bleeding tendency, and/or vascular disease. The case was diagnosed as spontaneous mesenteric hematoma.

The distribution of mental illness found by DIS (Diagnostic Interview Schedule) among internal and orthopedic patients.

In order to understand how psychiatric problems are distributed in general medical departments, we used DIS (Diagnostic Interview Schedule). The subjects are 307 inpatients and outpatients in the Departments in Internal Medicine and Orthopedics of Fukuoka University Hospital, M Hospital and N Hospital. As a result, 53.4% of all the subjects showed some psychiatric problems. These are, in a descending order, tobacco dependence (30.0%), psychosexual dysfunction (14.3%), alcohol abuse/dependence (14.0%), major depressive episode (6.5%), organic brain syndrome (4.9%), obsessive-compulsive disorder (3.9%), dysthymic disorder (2.3%), panic disorder (2.0%) and others. Also, we discussed comparison between internal patients and neurotic patients who visited psychiatrists complaining of physical symptoms, and the incidence of DIS diagnoses in individual physical diseases.

Neurosis from the viewpoint of DIS (Diagnostic Interview Schedule).

We examined the relationship between clinical and DIS-Lifetime diagnoses given independently on 106 psychiatric patients clinically diagnosed as suffering from neurosis. They had many coexisting DIS diagnoses, and some of them had no DIS diagnosis. The key to the coexistence relationships in DIS diagnosis was a major depressive episode, and the subjects were classified into four types by the DIS coexistence relationships; Type I: 28 cases (26.4%) had coexisting diagnoses belonging to anxiety disorders or somatoform disorders, in addition to a major depressive episode. They were suffering from clinically severe neurosis accompanied by borderline personality disorder. Type II: 30 cases (28.3%) belonged to anxiety disorders or somatoform disorders without a major depressive episode without anxiety disorders or somatoform disorders, and had clinically depressive neurosis or depressive episode with less distortion of the personality. Type IV: 30 cases (28.3%) were other than Type I-III, and were clinically similar to symptomatic neurosis.