What we must learn from the homeless mentally ill.
Explore the source record for details and available documents.
Activities of Daily Living↗
Biomedical subjects
N L Cohen
Publications and source records attributed to N L Cohen.
Onset and characteristics of the midcycle surge in bioactive and immunoactive luteinizing hormone secretion in normal women: influence of physiological variations in periovulatory ovarian steroid hormone secretion.
Limited studies in nonhuman primates suggest that the midcycle LH surge is characterized by distinctly different patterns of bioactive (LH-BIO) and immunoactive (LH-RIA) LH secretion. To further examine the patterns of midcycle LH-BIO and LH-RIA secretion and explore the influence of physiological variations in steroid hormone feedback on LH surge dimensions we studied seven normal ovulatory women over the periovulatory interval. In each, blood samples were obtained every 3 h and transvaginal ultrasonography was performed every 12 h over a 5-7 day interval at midcycle. Serum levels of LH-RIA, FSH, estradiol (E2), progesterone (P4), and 17-hydroxyprogesterone were determined by RIA; LH-BIO was estimated using a mouse leydig cell bioassay. Hormone data were standardized to the time of surge onset in LH-RIA (time zero), defined as a 100% increase above a 6-point running mean baseline value; surge cessation was defined as a decline to below baseline concentration. Mean LH-RIA surge duration was 54.0 +/- 4.0 h. LH-BIO surge onset was simultaneous with that of LH-RIA and coincident with the peak in E2 levels (mean data). Mean P4 and 17-hydroxyprogesterone rose in a parallel, phasic manner, an abrupt increase in slope occurred between -6 h and +30 h but an acute rise in P4 was not consistently observed among individuals. The surge onset to follicle rupture interval (mean 37.6 +/- 4.2 h) positively correlated with peak LH-RIA (r = 0.76, P less than 0.05), surge amplitude (r = 0.74, P less than 0.05) and surge onset to peak interval (r = 0.87, P less than 0.02), but not surge duration. There were no significant relationships between E2 or P4 (mean, peak, integrated, slope) and surge amplitude or duration (LH-RIA, FSH), peak value, or surge onset to peak interval (LH-RIA, LH-BIO, FSH). These data suggest that in women, 1) onset of the midcycle surge in LH-RIA and LH-BIO is simultaneous, and 2) surge characteristics are not influenced by physiological variations in steroid hormone secretion that occur beyond the thresholds required for surge initiation.
Adult↗
Use of a multichannel cochlear implant in the congenitally and prelingually deaf population.
Fourteen children and three adults, each congenitally and prelinguistically deaf, received the Nucleus multichannel implant. All underwent extensive evaluations and rehabilitation. The surgery was uneventful, and no patients have been lost to follow-up. Results have shown a significant increase in auditory and speech reception and perception skills in all children. Some children have open-set speech recognition using the prosthesis alone. The adults have shown an increased awareness of sound along with minimal improvement in perceptual skills. This supports the concept that early implantation of congenitally and prelinguistically deaf individuals results in improved performance.
Adult↗
Sensory aids in conjunction with cochlear implants.
The use of cochlear implants in profoundly hearing-impaired individuals can restore varying degrees of auditory capabilities. Although very little auditory information is transmitted to these patients through amplification systems, we hypothesized that some of the cues obtained from sensory aids might be helpful when used in conjunction with the cochlear implant postoperatively. Eight patients implanted at NYU Medical Center, Bellevue Hospital Center, have used some sensory aid in addition to the Nucleus multichannel cochlear prosthesis. All subjects were evaluated using standard auditory tests including pure-tone and speech audiometry, portions of the Minimal Auditory Capabilities (MAC), Speech Pattern Contrast Perception (SPAC), Iowa test batteries; and the Early Speech Perception (ESP), Word Intelligibility by Picture Identification (WIPI), and Glendonald Auditory Screening Procedure (GASP), where appropriate. Subjects were evaluated under three conditions: implant alone, implant plus sensory aid, and sensory aid alone. Results indicate that the interaction between a multichannel cochlear implant and a sensory aid can provide some improved performance for adult implanted patients (i.e., they do better under the dual condition than in the implant-alone condition). Variables such as thresholds in the nonimplanted ear and usage time can affect the outcome.
Adult↗
Cochlear implants in the management of bilateral acoustic neuromas.
Multichannel cochlear implants currently provide the only modality for successful auditory rehabilitation of patients with bilateral profound sensorineural hearing loss who derive no benefit from amplification. We have developed a protocol for patients with neurofibromatosis and bilateral acoustic neuromas in which every effort is made to preserve hearing in at least one ear. Failing that, the cochlear nerve is spared, potentially allowing for the insertion of a cochlear implant. We present our data on one such patient whose auditory function was restored with a Nucleus mini 22-channel cochlear implant following removal of his acoustic neuroma.
Adult↗
Spontaneous temporal bone cerebrospinal fluid leak.
Eight patients with spontaneous cerebrospinal fluid leak of temporal bone origin are presented. Pertinent history and surgical findings are reviewed and contrasted with 33 previously reported patients. Unilateral ear fullness and mild hearing loss are the most common presenting symptoms. Profuse clear otorrhea following myringotomy is virtually pathognomonic. Diagnostic methods including high-resolution computed tomography, magnetic resonance imaging, and contrast cisternography are discussed. The indications for transmastoid and combined transmastoid/middle fossa surgical repairs are compared. Both surgical approaches were found to be equally effective. We favor the transmastoid as the initial approach because of simplicity, safety, and the ability to visualize both the middle fossa and posterior fossa plates as well as the middle ear.
Adult↗
Retrosigmoid approach for acoustic tumor removal.
The retrosigmoid technique has evolved from the traditional suboccipital operation and, when combined with removal of the posterior wall of the internal auditory canal, affords a wide exposure of the cerebellopontine angle. This approach may be used for acoustic neuromas of all sizes, from intracanalicular to more than 4 cm from the porus acusticus. Hearing preservation may be attempted and is generally successful in a substantial minority of cases. The facial nerve is readily visualized at the lateral end of the internal auditory canal and is at no greater risk than in the translabyrinthine operation. We use this approach for all hearing preservation surgery as well as for tumors of more than 3 cm, regardless of hearing.
Cerebellum↗
Working the bugs out. Integrated pest management saves crops and the environment.
Explore the source record for details and available documents.
Agriculture↗
Emergency psychiatric intervention on the street.
The development of outreach approaches to engage and provide services to the homeless mentally ill must account for the heterogeneity of the population. The homeless mentally ill as a group are symbols of the failure of a comprehensive and integrated system of community-based care to develop in conjunction with the widespread proliferation of deinstitutionalization policies over the past several decades. Life in a community is far more complex and less easily controlled than life in an institution. People are free to reject the label of patient and refuse all mental health services. An engagement strategy must therefore be devised from the knowledge of specific aspects of a person's life in that community, so that outreach and networking efforts can be sensitive to the total context of the problems experienced by that patient. A multidisciplinary team approach is essential to the effort to engage and monitor those chronically mentally ill individuals who are at risk for psychiatric and/or medical decompensation. A variety of skills are needed, and team members must be flexible about their roles on the team. The clinician, while maintaining expert psychiatric, diagnostic, and treatment skills, must at the same time be able to adapt to people in their own environments, provide them with necessary social and medical services, and interface with other agencies working with these persons. The work is very labor intensive. It may involve two or more clinicians spending entire days with one patient. During a crisis state, these patients will require even more intensive attention from multiple team members to prevent decompensation and rehospitalization. In conclusion, there is no one intervention style in the work of psychiatric outreach. While the type of intervention offered follows from the mission of the outreach program, all outreach teams must be able to address the totality of needs of people who are fragile and at risk for psychiatric and medical decompensation. Case management services cannot be segregated easily from the task of crisis intervention in the work with the seriously mentally ill. The failure to establish an accessible network of community-based services for those chronically disaffiliated populations of mentally ill gives the outreach team the critical role of brokering any available services needed to support the individual in the community. The flexibility required of the outreach team derives both from the scarcity of community-based resources and the heterogeneity of the population of chronically ill adults who will most need these services.(ABSTRACT TRUNCATED AT 400 WORDS)
Community Mental Health Services↗
Medical treatment of endometriosis: a comparison of the suppressive effects of danazol and nafarelin on reproductive hormones.
OBJECTIVE: Patients with endometriosis were studied to investigate hormonal suppression by the gonadotropin-releasing hormone against nafarelin acetate compared with danazol. We hypothesized that the pattern, time course, and degree of gonadotropin and ovarian suppression would be different. DESIGN: The study included 16 patients who were randomized into one of three 6-month treatment protocols. SETTING: Patients were recruited from a university hospital setting. PATIENTS: Eligible candidates were 18 to 45 years of age, with regular menses and documented pelvic endometriosis. INTERVENTION: Six-month treatment protocols included nafarelin 800 or 400 micrograms/d, or danazol 800 mg/d. MAIN OUTCOME MEASURES: Serum estradiol (E2), progesterone (P), luteinizing hormone (LH), and follicle-stimulating hormone were determined before treatment and then monthly. Thirteen patients consented to a 12-hour hospital admission during the 5th and 6th month of treatment to determine LH pulse frequency and amplitude. RESULTS: Estradiol and P were suppressed in all groups, but E2 significantly more by nafarelin than danazol (P less than or equal to 0.01). Nafarelin, 800 micrograms, significantly depressed LH pulse amplitude compared with danazol (P less than or equal to 0.05). Two patients in the nafarelin group had the administration of their medication observed, and both demonstrated single, high-amplitude pulses immediately after administration. CONCLUSION: Nafarelin is a more potent LH and E2 suppressor than danazol, and the agonist effect of nafarelin may continue to provoke transient gonadotropin responses despite long-term therapeutic suppression.
Adult↗
The dizzy patient. Update on vestibular disorders.
Dizziness is often a patient's shorthand description of a variety of symptoms, many of which have nothing to do with balance. Vertigo consists of an abnormal sensation of motion, whereas dysequilibrium is a disturbance of balance without necessarily a sensation of motion. A careful history usually determines the nature of the patient's presenting symptoms, and a thorough workup will often give rise to a diagnosis. Vertigo of vestibular origin may be treated with a variety of medications or, when these fail, surgery. Surgery should preserve hearing when at all possible. Balance rehabilitation is a useful modality for the patient who does not compensate spontaneously or who does not respond to the medical or surgical treatment of imbalance.
Diagnosis, Differential↗
Surgical and safety considerations of multichannel cochlear implants in children.
Explore the source record for details and available documents.
Child↗
Cholesterol cysts of the temporal bone: diagnosis and treatment.
Cholesterol cyst (or granuloma) of the temporal bone, a recognized clinical entity distinct from cholesteatoma, is more common than previously thought. Apparently it is caused by obstruction of previously pneumatized temporal bone air cells. Surgical cure is achieved by drainage and reestablishment of normal pneumatization. This paper reviews 14 cholesterol cysts of the temporal bone, emphasizing the importance of preoperative imaging and surgical approach. Use of magnetic resonance imaging differentiates cholesterol cysts from cholesteatoma or other neoplasms. Computed tomography delineates the location of the lesion and defines temporal bone anatomy essential to surgical approach. The two studies together allow the surgeon to properly plan drainage, as in the case of a cholesterol cyst, versus excision or exteriorization, as in the case of cholesteatoma. The infralabyrinthine approach to a petrous apex cholesterol cyst is the procedure of choice when hearing preservation is desired.
Adolescent↗
Complications of cochlear implant surgery in adults and children.
Surgery for cochlear prosthesis insertion exposes the patient to several potential risks. We review the surgical complication experience with cochlear implants in the United States. There have been no deaths attributable to these devices, few serious major complications, and relatively few minor complications. Major complications usually have to do with surgical technique and include flap necrosis, improper electrode placement, and rare facial nerve problems. Minor complications include dehiscence of incisions, infection, facial nerve stimulation, dizziness, and pedestal problems with the Ineraid device. Complications were less frequent in children than adults and were more likely to occur in the younger children than those above the age of 7 years. Complications were still fewer in groups of patients operated on within tightly controlled protocols. There was no increased incidence of otitis media in children who received the Nucleus Mini-22 device, and no reported sequelae from such otitis when it occurred.
Adult↗
Prospective randomized clinical trial of advanced cochlear implants: preliminary results of a Department of Veterans Affairs Cooperative Study.
This study is a randomized clinical trial to compare the efficacy and safety of one single-channel implant (the 3M/Vienna intracochlear device) and two multichannel cochlear implants (the Nucleus 22-channel device and the Smith & Nephew Richards Ineraid device). Seven Veterans Administration centers are participating in the study. The patient population consists of 82 veterans with postlingual, bilateral profound sensorineural hearing losses who obtain no benefit from amplification. All potential subjects were screened with a battery of audiologic tests. The three device groups are balanced on baseline patient characteristics. One month after operation, the devices were stimulated and programmed and the patients evaluated. Follow-up evaluations were completed at 3 and 12 months poststimulation and then annually until the end of the study. The 12-month data indicate that performance with the multichannel devices is superior to that with the single-channel device.
Adult↗
Facial nerve stimulation with cochlear implantation. VA Cooperative Study Group on Cochlear Implantation.
The course of the facial nerve may place it within the current field generated by an activated cochlear implant to produce incidental facial movement. We investigated the presence of facial nerve stimulation associated with cochlear implants in the VA Cooperative Study of Advanced Cochlear implants. Twelve of 82 patients enrolled in this study demonstrated facial nerve stimulation within 2 years of implant activation. Facial nerve stimulation in six patients with multiple channel implants (Nucleus or ineraid devices) either resolved spontaneously (n = 2), or was eliminated by deactivating basal (n = 2) or apical (n = 2) electrodes. Two of six patients with single-channel electrodes (3-M/Vienna devices) demonstrated facial nerve stimulation that resolved spontaneously (n = 2), resolved with lowering current output (n = 2), or was refractory to processor adjustment (n = 2). Intraoperative assessment in one of the refractory cases indicated that facial nerve stimulation resulted from current spread through the modiolus to activate the facial nerve. A variety of factors, including implant design, stimulus parameters, and local tissue impedances, may interact to produce incidental facial stimulation. Low-impedance pathways between the scala tympani and the modiolus may deserve increased recognition as an interactive factor in cochlear implant performance.
Adult↗
Effects of chronic electrical stimulation on patients using a cochlear prosthesis.
Eighteen patients using the Nucleus multichannel cochlear prosthesis underwent annual evaluations for electrical thresholds, dynamic range, and speech recognition abilities for a period of 1 to 5 years. Results revealed no correlation between length of usage of a cochlear implant and electrical thresholds. The dynamic range was initially wider in the patients with open-set speech recognition, but narrowed in subsequent years. There was a correlation between length of deafness and postoperative performance.
Auditory Threshold↗
Extracranial repair of cerebrospinal fluid otorhinorrhea.
Forty-eight patients with cerebrospinal fluid leaks comprise this retrospective study. There were 39 traumatic and 9 spontaneous leaks. Nine patients were initially managed with bed rest and spinal drainage, but 3 patients in this group ultimately required surgical intervention for repair of their persistent leaks. Thirty-nine patients had surgery as initial therapy, with 33 extracranial repairs, 2 intracranial repairs, and 4 combined approaches. The extracranial approach was used in 36 of 42 patients, with an initial success rate of 86%.
Adolescent↗