Biomedical subjects
Publications and source records attributed to M D Bell.
We present an accidental autoerotic asphyxiation of a 24-year-old man. Further investigation revealed that 18 years earlier, his brother, then 13, had been found dead, hanging in the family bathroom. Although that death had been ruled a suicide, reevaluation of the death scene indicates that this was also an autoerotic asphyxiation. This is the first reported case of sexual asphyxia involving siblings.
Two unrelated male infants presented with brittle insulin-dependent diabetes mellitus in the first days of life. Subsequently they each developed severe secretory diarrhea, with stool volumes of more than 100 ml/kg/day. Extensive biochemical and serological investigation failed to reveal the etiology of the diarrhea. The infants, cared for at different institutions, underwent therapeutic trials of various agents including loperamide, cholestyramine, prednisone, indomethacin, and somatostatin analogue, without response. Both infants succumbed to septicemia and malnutrition related to diarrhea and poor control of glycemia. At autopsy, both were found to have absence of islets of Langerhans in the pancreas, and diffuse dysplastic changes in small and large intestinal mucosae. In particular, the entire alimentary tract in each case was lined by epithelia most typical of foregut mucosa: secretory-type glands, absent crypts of Lieberkuhn, and absent villi. These cases are contrasted with previously-reported infants with congenital diabetes mellitus, and the possible interrelation of these two highly unusual findings, congenital diabetes mellitus and diffuse intestinal dysplasia, is examined.
Eight patients were presented to the medical examiner after dying suddenly and unexpectedly from thrombotic thrombocytopenic purpura. Compared with patients who die after prolonged hospitalization and treatment, these patients showed fewer neurologic symptoms and correspondingly fewer or no microthrombi within the brain. Only four of eight subjects developed fever, which further contributed to misdiagnosis. The differences in clinical presentation between our cases and most published series is striking and may be explained by shorter duration and no treatment. Each case contained the characteristic histology of thrombotic thrombocytopenic purpura. Ischemic injury to the heart and conduction system was the most likely mechanism of sudden death. Included in this series is a patient with acquired immunodeficiency syndrome (AIDS) diagnosed at autopsy, a concurrence that is now appearing more frequently in the medical literature.
The anaesthetic management of a 27-year-old woman who presented for surgical correction of hypertrophic obstructive cardiomyopathy and mitral valve prolapse is described. The rationale for using propofol in a total intravenous anaesthetic technique is discussed.
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The analgesic effects of buccal and intramuscular morphine were compared in a prospective, double-blind, double-dummy study in forty patients who experienced pain after elective orthopaedic operations. Each patient simultaneously received a buccal tablet and an intramuscular injection, only one of which contained morphine sulphate (13.3 mg); the patients were randomly allocated to two equal groups so twenty patients received each active preparation. The two preparations produced a similar degree of postoperative analgesia, assessed by the mean reduction in pain score and the pain relief score. Peak plasma morphine concentrations were slightly lower after buccal than after intramuscular administration but they declined more slowly; consequently, the drug's bioavailability was 40-50% greater after buccal than after intramuscular administration. The adverse effects of buccal morphine were generally less than those of intramuscular morphine.
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Staff views about the actual and ideal treatment environment of three therapeutic milieus with psychoanalytic, biological, and rehabilitative orientations were assessed using the Community-Oriented Programs Environment Scale (COPES), real and ideal forms. COPES scores indicated that the staff of the three units shared many beliefs about the ideal milieu but that only staff of the rehabilitation unit felt the milieu had realized its ideals. Disparities between real and ideal COPES scores on the other two units were believed to reflect staffs' inability to resolve the conflicting demands of milieu therapy and other treatment approaches. The authors identify specific sources of conflict on the psychoanalytic and biological milieus and reasons for the greater compatibility of ideology and practice in the rehabilitation milieu.
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Three therapeutic communities for drug abusers were compared using the Community Oriented Program Environments Scale (COPES) to determine whether the same principles of treatment could produce similar social environments. All three facilities were found to have similarly shaped profiles. Two of the facilities differed significantly from each other on only two subscales, with standard scores remaining within the same range. The third facility showed a depressed profile that differed significantly from the other facilities on five subscales and suggested a poorer quality of treatment environment. Further evidence for this interpretation came from a follow-up study of dropouts from the three facilities; it was found that the two facilities with similar scores had similar dropout rates, while the third facility with lower scores had a much higher dropout rate.
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Psychosocial rehabilitation services, while sorely needed by patients with prolonged mental illness, are not usually offered as part of hospital psychiatry. The authors describe the Veterans Resource Program (VRP), a hospital-based psychosocial rehabilitation program, as a model for introducing rehabilitation services into a hospital psychiatry system. Its perceived residential treatment environment was found to be more practically oriented and to provide more autonomy for patients than did an intensive treatment unit, while still possessing many supportive relationship characteristics. The authors found that the VRP patients had very low dropout and relapse rates; VRP patients also had better recidivism and employment rates compared with baseline rates and with patients in two comparison programs. These results suggest that integrating rehabilitation into hospital psychiatry improves patient care.
This paper describes the perceived treatment environment of a unit that strongly espoused the psychoanalytic model. Six-month follow-up data indicate that symptom ratings, recidivism, and employment were indistinguishable from baseline rates. The program's emphasis on uncovering feelings and transference phenomena and its neglect of practical psychosocial problems are discussed.
Wallerian degeneration in the PNS is accompanied by the rapid recruitment of monocytes, but monocytes do not invade CNS fibre tracts undergoing Wallerian degeneration. In recent years it has become apparent that the acute inflammatory response to cell degeneration in the CNS is unlike that in other tissues. We have been interested to learn why Wallerian degeneration does not provoke a typical inflammatory response. We investigated whether the vascular endothelial cells express adhesion molecules during Wallerian degeneration in PNS and CNS. We found that in the degenerating sciatic nerve there was upregulation of ICAM-1 and VCAM-1 expression on endothelial cells in the distal stump of the injured nerve as well as at the site of the lesion. However, in the degenerating optic nerve, the endothelium failed to upregulated these molecules in the distal stump of the nerve and ICAM-1 expression was only increased in the crush site. The lack of adhesion molecule expression on CNS endothelium molecules may be an explanation for the poor leukocyte recruitment during Wallerian degeneration in CNS when compared with PNS.
Weekly assessments of depression, anxiety, and positive and negative symptoms were performed on 80 subjects with schizophrenia or schizoaffective disorder. Using procedures previously reported in another study, the frequency of significant correlations between the sum of anxiety and depression ratings and positive symptoms was compared with the frequency of significant correlations between the sum of anxiety and depression ratings and negative symptoms. Results confirm that dysphoria in schizophrenia tends to be more frequently associated with positive versus negative symptoms, regardless of diagnostic subtype or symptom type. This provides further evidence of the independence of negative symptoms from dysphoria and suggests that the level of positive symptoms and level of dysphoria may mutually influence one another.
OBJECTIVE: Since CNS nocardiosis is an often fatal yet potentially treatable infection in HIV patients, we sought to identify and characterize imaging features that may suggest the diagnosis in the appropriate clinical setting. MATERIALS AND METHODS: The CT scan (six), MR scans (one), or both (two) were evaluated in nine HIV patients with pathologically proven CNS Nocardia asteroides. Chest X-ray films were available in seven patients. Findings were correlated with pathologic examination. RESULTS: All nine patients had brain abscesses, and in seven that received intravenous contrast agent, all lesions demonstrated ring enhancement. Five of nine patients had hydrocephalus and four of these had clinical evidence of meningitis. Small subependymal nodules were seen in five of nine patients and four of these also had meningitis. Pathologic examination in three of nine cases demonstrated a dense inflammatory infiltrate lining the ventricles that extended through the ependymal lining, producing small subependymal abscesses. Six of seven available chest X-ray films demonstrated infiltrates due to Nocardia. CONCLUSION: Our radiologic-pathologic correlation indicates that in an HIV-positive patient with enhancing parenchymal lesions, the additional findings of subependymal nodules and/or meningitis may suggest the diagnosis of nocardiosis. An associated pulmonary infiltrate can provide a clue to the diagnosis and serve as more accessible site for biopsy or culture.
PURPOSE: To characterize the radiographic findings on neuroimaging of 25 human immunodeficiency virus (HIV)-seropositive patients with proved central nervous system tuberculosis and to correlate those findings with clinical data. METHODS: Twenty-five HIV-seropositive patients with central nervous system tuberculosis were identified, and their imaging studies (CT and, in some cases, MR) and medical records were reviewed. The diagnosis of central nervous system tuberculosis was based on cerebrospinal fluid culture (n = 20), biopsy (n = 4), and/or autopsy (n = 5), with a clinical diagnosis of central nervous system tuberculosis in one additional patient. Results also were correlated with CD4 counts and chest x-ray findings. RESULTS: Nine (36%) of 25 patients demonstrated meningeal enhancement. Eleven (44%) of 25 demonstrated enhancing parenchymal lesions; 6 patients had tuberculomata, and 5 had tuberculous abscesses. Communicating hydrocephalus was present in 8 (32%) of 25, and infarction was seen in 9 (36%) of 25. Fifteen of 23 chest x-rays were suggestive of pulmonary tuberculosis. Mean CD4 count was 162. Nine (38%) of 24 patients had a history of pulmonary tuberculosis, and 5 (21%) of 24 had no history of tuberculosis or any other opportunistic infection. Overall mortality was 79%. CONCLUSION: Central nervous system tuberculosis has a very high mortality among HIV-infected patients. Because cerebrospinal fluid cultures can take 6 to 8 weeks, the neuroradiologist can play a critical role in patient treatment by suggesting the correct diagnosis based on characteristic imaging findings. Radiographic clues include multiloculated abscess, cisternal enhancement, basal ganglia infarction, and communicating hydrocephalus, which are not findings associated with the more commonly encountered central nervous system lymphoma or toxoplasma encephalitis. Central nervous system tuberculosis may be the initial presentation of acquired immunodeficiency syndrome. In patients with suspected central nervous system tuberculosis, chest x-ray may provide additional support for the diagnosis of tuberculosis.