Phenytoin penetration into chronic subdural haematomas.

The pathophysiology of chronic subdural haematomas (CSH) is still unclear. In the light of recent ultrastructural examination, exudation from the macrocapillaries in the outer membrane of CSH may play an important role in the enlargement of CSH. In this study, exudation from the macrocapillaries was assessed by the measurement of phenytoin, a protein-bound antiepileptic agent used in cases of CSH. In 22 patients, 1 h after the administration of 250 mg of phenytoin intravenously, blood and subdural haematoma samples were taken and phenytoin levels were measured. The ratio of subdural haematoma level to the blood phenytoin level was determined and defined as the phenytoin penetration ratio (PPR). The correlation between the phenytoin penetration ratio and clinical neurological grades (Markwalder and Glasgow Coma Scale), age of the patients and the CT appearance of CSH were investigated. The mean phenytoin penetration ratio was 19.5%. As the neurological grades of patients increased, average PPR also increased. The average PPR values were 17.64 and 20.84% in the patients younger than 60 years (nine patients) and older patients (13 patients), respectively. Mean PPRs in the groups according to the CT appearance were as follows: low density 11.21% (seven patients), isodensity in 15.88% (10 patients), high density in 38.5% (five patients). A subdural reaccumulation was detected in nine patients with a mean PPR of 27.72%, while mean PPR was 14.56% in the others. Exudation from macrocapillaries in the outer membrane of chronic subdural haematomas probably plays an important role in the enlargement of chronic subdural haematoma, and measuring phenytoin levels in the chronic subdural haematoma is a simple method for the quantitative estimation of the exudation in CSH.

Potentially reversible cognitive impairment in patients presenting to a memory disorders clinic.

This paper aims to describe a memory disorders clinic (MDC) for the assessment of patients presenting with early cognitive impairment, to examine the predictive utility of laboratory tests conducted on patients with early memory complaints, and, to investigate the potential reversibility of cognitive impairment in 80 consecutive patients presenting to an MDC. Abnormal laboratory results did not significantly correlate with diagnosis at presentation, with presence or absence of cognitive impairment at presentation or at one year follow up, or with cognitive outcome. Thorough assessment of a person presenting with memory impairment is mandatory. We suggest that a routine battery of laboratory investigations be replaced with selected investigations based on clinical indicators only. The term 'reversible dementia' is a misnomer, and we recommend instead the use of 'potentially reversible cognitive impairment'. We argue that the term 'dementia' should only be used to describe cognitive impairment in cases of irreversible degenerative brain disease.

Descriptors of depression: the importance of agreed definitions.

OBJECTIVE: We suggest that some descriptors and criteria of depressive features lack clarity or are overinclusive, with definitional limitations and vagaries in rating options, leading to variable ratings of similar items across differing measures as well as cloudy interpretation of positive ratings. METHOD: We illustrate these limitations by reference to two items: 'guilt' and 'distinct quality of mood'. RESULTS: We note problems emerging from confounded and imprecise definitions. CONCLUSIONS: We emphasise the need for definitions of depressive descriptors possessing greater specificity.

To whom do you refer? A referrer satisfaction study.

OBJECTIVE: To report the development of a referrer satisfaction measure. METHOD: Urban and rural general practitioners, physicians, neurologists, as well as obstetricians and gynaecologists rated 36 items in terms of their judged importance to the respondent's satisfaction with a psychiatric service. Responses of the whole sample and component practitioner sub-groups were ranked. RESULTS: We established a high level of agreement across the several subgroups suggesting that we had identified general rather than idiosyncratic variables contributing to referrer satisfaction. Referrers prioritised as most important the immediacy of initial appointment, the psychiatrist reporting at the beginning and end of any treatment course, and ready verbal communication between the referrer and the psychiatrist. Items accorded low priority were the psychiatrist's billing arrangements, the psychiatrist being 'perfect' (in either having a high 'cure' rate or making a definitive diagnosis initially), or the psychiatrist taking complete responsibility for difficult patients. A principal components analysis identified four factors underpinning the item set, and we again established that scores on these factors were not influenced by the particular referrer sub-group. CONCLUSIONS: Such findings suggest that only minor modifications would need to be made to the item set in developing a referrer satisfaction measure for quality assurance activities.

The early history of convulsive therapies in Australia.

The early experience of convulsive therapies in Australia was reported in the Medical Journal of Australia from 1935 to 1950. Cardiazol convulsive therapy, first used in Australia in 1937, appears to have been widely employed. Electroconvulsive therapy, first used here in 1941, rapidly became accepted as a mainstream treatment. Early response rates are discussed, as well as Australian adaptations of European techniques. Clinicians of the day considered the use of these procedures carefully and were circumspect about their future role.

Using ambulance service records to examine nonfatal heroin overdoses.

Overdoses are a preventable health hazard associated with heroin use. In the first study of its kind, we examined the records on nonfatal overdoses of the Australian Capital Territory (ACT) Ambulance Service from August 1990 to July 1993. There was a dramatic increase in the number of overdoses in the second half of 1992 and the first half of 1993, but the reasons for the increase are not clear. Most overdoses occurred in men aged under 30, indoors, and many cases were taken to hospital. Often there was no information on why the overdose occurred; when information was available, about half the cases were attributed to taking heroin in combination with other drugs. Suggestions for improving the quality of the data collected are made. These include more systematic recording by ambulance officers of the drug involved in the overdose and whether the drug was used alone or in combination with others, and linkage of ambulance service records with survey data and information from analysis of heroin purity.

The Canberra Christmas overdoses mystery.

Our investigation of a cluster of three fatal overdoses casts doubt on the conventional wisdom that overdoses result from unregulated changes in the purity of street heroin. Use of alcohol or other sedatives can make an otherwise safe dose of heroin (or other opioids) lethal. In addition users can knowingly increase their dose, usually as an indulgence. Some media reporting of this cluster of deaths was accurate, but there was also sensationalization, perpetuating stereotypes about the drug market that may be untrue. Information flow within the using community was relatively accurate, but slow, possibly because it was the holiday season. Larger studies to substantiate our findings are needed. In addition, introduction of a user-organization-based epidemiological monitoring system for overdoses would be a valuable public health measure.

Treatment resistant depression in an Australian context. II: Outcome of a series of patients.

The clinical characteristics and treatment outcome of a series of 107 patients referred to a mood disorders unit with an episode of "treatment resistant" Major Depression are reviewed. Subjects were categorised by diagnosis (into melancholic and non-melancholic subtypes) and by adequacy of previous treatment. At subsequent review (mean period of 37.5 months) these patients were re-assessed both in terms of outcome and which treatments had been considered to be most effective. Forty one percent of the patient group were fully recovered and a further 43% were partially improved. Different treatments were considered effective for melancholic and non-melancholic sub-types.

A brief self-report depression measure assessing mood state and social impairment.

Many measures of depression severity appear confounded by including depressive sub-typing features. We report the design of a brief (11 item) self-report scale of depression severity (the AUSSI), assessing both mood state and social impairment domains, and designed to be independent of sub-typing features. Mood severity and functional impairment scores demonstrated some independence in a sample of 360 patients. Patients with a 'melancholic' depressive type (categorised by four differing systems) differed from residual 'non-melancholic' depressed patients by having higher impairment scores, but the assigned groups did not differ, in the main, by mood severity scores. Advantages of the measure are summarised.

Community Health and Medical Practitioners Scheme: providers evaluate a pilot program of integration of services.

OBJECTIVE: To set up and evaluate a pilot scheme integrating salaried community health centre staff and fee-for-service medical practitioner services (CHAMPS). DESIGN: Preliminary interviews with both groups established the aims, logistics and financial arrangements of the project. The community health centre provided staff and the general practitioners provided premises and administrative services. Follow-up interviews evaluated the scheme and made recommendations. SETTING: A New South Wales country town, population 24,000, with 25 general practitioners and 23 community health centre professionals. RESULTS: Six general practitioners and 23 community health professionals determined the aims to be: improved access for patients to community health services; improved liaison between the two groups of providers; and a broadening of services offered at general practice locations. Two dietitians and three mental health workers were rostered for half a day per week in four general practices for six months. The dietitians continued after the project finished, but the mental health workers did not. The five community health staff, five of the general practitioners originally interviewed and six other general practitioner participants cited the major benefits as increased communication between providers and improved access for patients, and the major difficulties as lack of appropriate equipment and organisational logistics. CONCLUSIONS: The providers believe that the project succeeded in improving access to community health services and liaison between professionals. For future projects they recommended better communication, firmer role delineation and better planning for space and equipment.