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Relationship between symptom over-reporting and pre- and post-combat trauma history in veterans evaluated for PTSD.

We examined the prevalence of pre- and post-combat traumatic events in the histories of 129 combat veterans referred to be evaluated for PTSD and examined the impact of these non-combat traumatic events on self-reported psychiatric symptoms. Participants were consecutive referrals to a Veterans Affairs outpatient post-traumatic stress disorder (PTSD) clinic who completed structured interviews, self-report measures (e.g., Minnesota Multiphasic Personality Inventory-2; MMPI-2), and a trauma history questionnaire as part of their routine clinical evaluations. Findings show that non-combat trauma was prevalent in this sample, with 65% (21% pre-combat) reporting physical assaults and 12% (11% pre-combat) reporting sexual assaults. Overall, history of sexual or physical assaults did not appear to be systematically related to reported symptom level. However, chi square analyses revealed a consistent over-representation of veterans who reported sexual trauma in the category suggestive of response exaggeration (i.e., MMPI-2 F-K validity index > or = 13). Finally, a hierarchical regression equation predicting F-K scores was computed, but accounted for only 15.9% of the variance in F-K. Presence of sexual assault history was the only predictor associated with a more pronounced response set suggestive of exaggeration or deception. These findings tentatively indicate that if history of sexual or physical assault has an impact on symptom reporting in combat veterans evaluated for PTSD, it is of modest magnitude.

Adult↗

Diagnosis and surgical treatment of childhood brain tumors.

As the most frequent solid tumor occurring in childhood, brain tumors constitute an important segment of pediatric oncology. Neurologic manifestations may be deceptively mild and easily overlooked or misinterpreted, particularly in the very young, because of the remarkable resiliency of the immature central nervous system and the skull's ability to expand throughout the pre-adolescent years. The majority of childhood tumors produce increased intracranial pressure, usually the consequence of obstructive hydrocephalus. Specific neurologic deficits correspond to the tumor's location. The posterior fossa harbors two-thirds of childhood tumors, and each of the four common tumors in this location produces a characteristic syndrome. Supratentorial tumors occupy the cerebral hemisphere, the suprasellar area, and the pineal gland. Diagnostic studies have reached a state of great sophistication and precise anatomical localization. Surgery, either alone or with adjuvant radiotherapy, cures no more than one-third of all tumors; for the remainder, it has a diagnostic and palliative role. The introduction of operative microsurgery has advanced the art, particularly in the surgical treatment of craniopharyngiomas and pinealomas, but any significant improvement in the treatment of brain tumors as a group seems unlikely to be achieved by surgery alone.

Animals↗

Pitfalls in microscopic diagnosis of undifferentiated carcinoma of nasopharyngeal type (lymphoepithelioma).

Isolated cervical lymph node metastases from undifferentiated carcinoma of nasopharyngeal type (UCNT) or lymphoepithelioma (LE) pathologically may be mistaken for malignant lymphomas. The case histories of four patients in whom metastatic UCNT in lymph nodes pathologically simulated Hodgkin's disease (HD) and other non epithelial malignancies are reported. Initial lymph node biopsies showed a cellular and architectural context suggestive of HD in three cases. "Lacunar" cells were seen associated with fibrosis and numerous eosinophils in Case 1; cells indistinguishable from diagnostic Reed-Sternberg cells were recognized in Case 4. Case 3 showed some additional features suggestive of malignant histiocytosis. Subsequent biopsies revealed a primary UCNT of the nasopharynx (Case 1) and typical UCNT lymph node metastases (Cases 3 and 4). In Case 2, an immunoblastic lymphoma and a spindle cell sarcoma, respectively, were mimicked by consecutive lymph node metastases. A primary UCNT of palatine tonsil was found five years later. This report emphasizes that deceptive features of metastatic UCNT in lymph nodes may produce serious difficulties in the correct recognition of the tumor on pure histologic grounds. In order to minimize the possibility of misdiagnosis, additional cytochemical, immunohistochemical and serologic studies should be considered, especially when a young patient presents with spinal or infraclavicular lymphadenopathies and no lesion is evident in the nasopharynx.

Adolescent↗

Secondary ovarian neoplasia. A clinicopathologic study of 35 cases.

The authors reviewed the clinical and pathologic features of 35 cases of secondary ovarian neoplasms in which the clinical presentation was that of a primary ovarian tumor. The most common secondary neoplasms to mimic an ovarian tumor were colonic adenocarcinoma, breast carcinoma, lymphoma, carcinoid, and gastric adenocarcinoma. It was found that a classification based on gross appearance was useful in evaluating these neoplasms. Solid neoplasms with either a diffuse or nodular gross appearance had distinct histologies so that accurate diagnosis was possible. Cystic neoplasms, especially colon adenocarcinomas, were deceptive and frequently misclassified as primary ovarian adenocarcinoma. Since all of the metastatic colonic carcinomas had mucus-containing cells, the main differential diagnosis was between metastatic colonic carcinoma and primary mucinous carcinoma of the ovary. The absence of a mucus-cell predominant pattern and the lack of transition from benign-appearing epithelium to malignant epithelium are two useful criteria in making this important distinction. Other features may also prove helpful.

Adolescent↗

The fibroma-like variant of epithelioid sarcoma. A fibrohistiocytic/myoid cell lesion often confused with benign and malignant spindle cell tumors.

Five cases of a previously undescribed variant of epithelioid sarcoma are presented. This variant differs from the usual lesion in its absence of the typical necrobiotic nodular epithelioid pattern. It is instead composed of deceptively bland fibrohistiocytic and myoid cells arranged in a fibroma-like or dermatofibroma-like pattern with an affinity for osseous involvement. The clinical presentation, ultrastructural features, and presence of vimentin and low molecular weight keratin within the tumor cells justifies their designation as an epithelioid sarcoma variant.

Adolescent↗

Differential expression of cell adhesion molecules in B-zone small lymphocytic lymphoma and other well-differentiated lymphocytic disorders.

BACKGROUND: Cell adhesion molecules (CAM) may determine the patterns of growth and dissemination of lymphoproliferative disorders. METHODS: The authors have studied, by flow cytometric and immunohistochemical examination, the expression of several CAM, mediating cell-cell and cell-microenvironment interactions, on B-zone small lymphocytic lymphoma (BZSLL) and other B-cell low-grade non-Hodgkin lymphomas (NHL), including intermediate lymphocytic/mantle zone lymphoma (ILL/MZL), small lymphocytic lymphoma (SLL), and chronic lymphocytic leukemia (CLL). RESULTS: Relevant differences in the "adhesion phenotype" of BZSLL compared with other low-grade NHL examined were evidenced. Cells from BZSLL displayed a higher rate of expression and/or a stronger intensity of LFA-1, LFA-3, ICAM-1, and BL-CAM and a lower density of H-CAM and LAM-1 homing receptors, as opposed to SLL or CLL. A lower intensity of H-CAM along with a stronger expression of LFA-1, LFA-3, ICAM-1, and BL-CAM were also detected by comparing BZSLL with ILL/MZL: Malignant cells from BZSLL expressed Leu-CAMb determinants in three cases. BZSLL cells lacked VLA-alpha 5-integrins as opposed to CLL lymphocytes and displayed a stronger reactivity with anti-VLA-alpha 4 antibodies with respect to ILL/MZL and CLL. beta 1-integrins were consistently detected on BZSLL lymphocytes as opposed to ILL/MZL: CONCLUSIONS: These data suggest that the adhesion phenotype of BZSLL, by favoring homotypic and heterotypic adhesive interactions of tumor cells, might account at least in part for the peculiar intranodal compartmentalization leading to a deceptively benign (reactive) histologic appearance, and for the smoldering clinical course of this lymphoma. The pattern of CAM expression detected by the authors on malignant lymphocytes also is suggestive for a cellular origin of BZSLL from a rare subset of interfollicular or external mantle B-lymphocytes.

Cell Adhesion Molecules↗

Role of expectancy set in the systematic desensitization of speech anxiety: an extension of prior research.

The influence of expectancy set with regard to therapy outcome on the effectiveness of systematic desensitization (SD) for reducing public speaking anxiety was investigated. The 7 Ss given a high expectancy set for favorable therapy outcome were informed about psychological research that indicates that SD is effective to reduce public speaking fears. SD was administered with the standard instructions to the 11 Ss given a neutral expectancy set. This expectancy manipulation did not require deception and perhaps could be used with actual SD therapy clients. As in previous research by Woy and Efran, the expectancy set manipulation significantly modified Ss' self-report of subjective perceptions of anxiety from pretreatment to posttreatment speeches, but did not affect overt behavioral or physiological indices of anxiety. Since subjective perceptions of anxiety responses are psychologically significant behaviors, these data suggest the importance of conveying a high expectation of improvement to SD and perhaps also to other types of therapy clients. SD sessions administered to small groups of clients on consecutive days, as in this study, appeared to be as effective to reduce speech anxiety as SD sessions administered to each client individually at 1-week intervals, as in the Woy and Efran study.

Anxiety↗

Placebo insight: the rationality of insight-oriented psychotherapy.

It is widely believed that the insight-oriented psychotherapies provide their clients with valid methods of self-exploration that lead to bona fide self-knowledge. It also is widely believed that clients' insights must be true in order to be therapeutically effective. Both these claims are implausible. I argue that because clients face significant epistemic pressures in the therapeutic encounter, the insight-oriented psychotherapies are highly susceptible to generating placebo insights, that is, illusions, deceptions, and adaptive self-misunderstandings that convincingly mimic veridical insight but have no genuine explanatory power. The insight-oriented psychotherapies also are highly susceptible to generating therapeutic artefacts that appear to confirm the insights acquired by clients. The powerful treatment methods to which clients are subjected generate some of the very psychological and behavioral facts that clients claim to "discover" in their explorations. This impugns the scientific status of the insight-oriented psychotherapies.

Humans↗

Cost-effectiveness analysis: what is it and how will it influence neurology.

Cost-effectiveness analysis (CEA) refers to a set of research methods that consider the resources consumed by a medical technology in decisions about how best to use the technology. This analytic method is an evolving, controversial, and often misunderstood field in health services research. The basic set of principles underlying CEA is deceptively simple, but sufficient methodological challenges and controversies exist that have, thus far, limited its use in the development of health policy and in bedside decision making. Nonetheless, neurologists like other specialty groups may feel concerned that the results from such analyses may prove unfavorable to their specialty and the patients they serve. This article reviews the fundamental notions surrounding CEA, provides examples from the literature with particular relevance to the neurological community, and highlights critical issues for neurologists regarding the future of CEA.

Cost-Benefit Analysis↗

Mechanisms of synovial joint and articular cartilage formation: recent advances, but many lingering mysteries.

Synovial joints are elegant, critically important, and deceptively simple biomechanical structures. They are comprised of articular cartilage that covers each end of the opposing skeletal elements, synovial fluid that lubricates and nourishes the tissues, ligaments that hold the skeletal elements in check, and a fibrous capsule that insulates the joints from surrounding tissues. Joints also exhibit an exquisite arrays of shapes and sizes, best exemplified by the nearly spherical convex femoral head articulating into a nearly spherical concave hip acetabulum, or a phalangeal joint with two condyles on the distal side articulating in reciprocally-shaped sockets on the opposing proximal side. Though few in number, joint tissues are highly specialized in structure and function. This is illustrated by articular cartilage with its unique extracellular matrix, unique biomechanical resilience, its largely avascular nature, and its ability to persist through life with minimal turnover of its cells and components. The fact that interest in synovial joints has remained unabated for decades is a reflection of their fundamental importance for organism function and quality of life, and for their susceptibility to a variety of acquired and congenital conditions, most importantly arthritis. This has led to many advances in this field that encompass molecular genetics to biomechanics to medicine. Regrettably, what continues to be poorly understood are the mechanisms by which synovial joints actually form in the developing embryo. If available, this information would be not only of indisputable biological interest, but would also have significant biomedical ramifications, particularly in terms of designing novel tissue regeneration or reconstruction therapies. This review focuses on recent advances in understanding the mechanisms of synovial joint formation in the limbs, and places and discusses the information within the context of classic studies and the many mysteries and questions that remain unanswered.

Animals↗

Isolated complete transection of the common bile duct by blunt abdominal trauma.

Isolated complete transection of the common bile duct due to blunt trauma is rare. Its occurrence and successful treatment in an 8-year-old boy are described. Inital minor peritonism resolved quickly, followed by a deceptive asymptomatic period and insidious development of jaundice, anorexia, vomiting, pain, acholic stools and progressive abdominal distension due to sterile biliary ascites. A preliminary cholecystostomy was followed by construction of a Roux-en-Y cholecystojejunostomy.

Abdominal Injuries↗

Psychopathy and malingering of psychiatric disorder in criminal defendants.

Because the use of deception is an important clinical characteristic of psychopathy, there is intuitive appeal to the idea that psychopathy and malingering are associated. There is, however, very little research showing that psychopaths are more likely to malinger. We classified a sample of criminal defendants as high, moderate, or low in psychopathy, based on PCL-R scores, and compared their scores on indices typically used to detect malingering on the MMPI-2, the PAI and the SIRS. The high psychopathy group scored significantly higher on the MMPI-2 F and F-K; the PAI NIM, and the SIRS, but not the MMPI-2 Fb, F(p), or the PAI RDF or Mal, lending some support for the DSM-IV recommendation that malingering should be considered whenever there is a diagnosis of antisocial personality disorder. Logistic regression analysis (LGA) revealed that Factor I but not Factor II of the PCL-R significantly discriminated malingerers from nonmalingerers with 75% correct classification. However, receiver operating characteristic (ROC) analysis revealed that psychopathy ratings had poor sensitivity and specificity in the detection of malingering. Calculation of the percentages of those exceeding accepted cut-offs on each of the malingering measures revealed that a high percentage of severe psychopaths did not attempt to feign psychiatric disorder. The results suggest that psychopathy is not a clinically useful indictor of malingering. The results are discussed in terms of confirmatory bias and the impact such a bias could have on the evaluation of criminal defendants.

Adult↗

Comparing the constructs of antisocial personality disorder and psychopathy in a sample of incarcerated women.

Our study examines the relationship between Antisocial Personality Disorder (APD) and psychopathy among a sample of 137 female offenders. Drawing from a historical review of the evolution of these two concepts, we explore their differential relationship to patterns of criminal behavior, psychological adjustment, co-morbidity with other personality disorders, victimization, and institutional adjustment. Findings suggest that the two disorders share a common foundation of social norm violations and deception; however, APD is associated with impulsive, aggressive, and irresponsible behavior, higher rates of childhood abuse, and greater co-morbidity with Cluster A PDs, while psychopathy is better characterized by higher rates of property crimes, previous incarceration, and the manifestation of remorselessness. Results contribute to a further understanding of the etiology and phenomenology of these two disorders and suggest different types of treatment and intervention.

Adult↗

Sternomastoid paradox.

In the standard routine for testing cranial nerve function following a cerebrovascular accident (CVA) compromising the corticonuclear supply to the cranial nerves, sternomastoid muscle (SCM) function is checked by means of head rotation against resistance. SCM appears to be an exception to the generally contralateral motor weakness resulting from a CVA. The thrust of this article is that appearances can be deceptive: SCM is more likely to be a postural stabilizer than a prime mover in head rotation.

Cranial Nerves↗

Noninvasive determination of valve area in adults with aortic stenosis using Doppler echocardiography.

Doppler ultrasound has been used to determine the pressure gradient P1-P2 across the valve in patients with aortic stenosis (AS), but since the gradient varies over time and may be deceptively low in patients with impaired cardiac output, the key parameter to obtain is the orifice area (A). By calculating stroke volume (SV) from the modal flow velocity [Vmode(t)] over the systolic ejection period (sep) or diastolic filling period (dfp), wherever laminar flow exists in the heart across an area of known diameter D, (pulmonary artery or atrioventricular valves), and by substituting P1-P2 = 4Vmax2, (Vmax = peak velocity in the aortic jet), the Gorlin formula becomes: (Formula: see text) where theta = flow intercept angle at D. This approach was applied in nine adult patients with AS (age 64 +/- 8 years) in whom recent catheterization data was available for comparison. Close correlation was found between the calculated areas: A(Doppler) = 0.82 A(Cath) + 0.17 (r = 0.94, p less than 0.001). Two patients with Doppler gradients of less than 40 mmHg were shown by this Doppler method nevertheless to have severely narrowed orifice areas of less than or equal to 0.78 cm2. Although there is a tendency to overestimate slightly the valve area, Doppler ultrasound assessment using this technique adds valuable noninvasive information concerning the degree of aortic valve disease.

Aged↗

A short and concise asymmetric synthesis of hamigeran B.

The interesting biological properties of the hamigerans wherein hamigeran B is a potent antiviral agent with low cytotoxicity to host cells make these deceptively simple looking structures challenging synthetic targets. A strategy to hamigeran B evolved wherein the three contiguous stereocenters are established ultimately from a Pd catalyzed asymmetric allylic alkylation (AAA). The latter involves an asymmetric allylation of a non-stabilized ketone enolate in 77 % yield and 93 % ee. By using this process, (S)-5-allyl-2-isopropyl-5-methyl-1-trifluoromethanesulfonyloxycyclopentene becomes available in four steps from 2-methylcyclopentanone. Introduction of the aryl unit by cross-coupling proceeded intermolecularly but failed intramolecularly. On the other hand, reductive removal of the triflate permitted a Heck reaction to effect intramolecular introduction of the aryl ring. The unusual conformational properties of this molecular architecture are revealed by the regioselectivity of the beta-hydrogen elimination in the Heck reaction and the diastereoselectivity of the reduction establishing the stereochemistry of the carbon bearing the isopropyl group. The successful route consists of 15 steps from 2-methylcyclopentanone and dimethylorcinol illustrating the efficiency of the route based upon the Pd AAA.

Hydrogenation↗

On the first polyarsenic organic compound from nature: arsenicin A from the New Caledonian marine sponge Echinochalina bargibanti.

Reported here is the first polyarsenic compound ever found in nature. Denominated arsenicin A, it was isolated along a bioassay-guided fractionation of the organic extract of the poecilosclerid sponge Echinochalina bargibanti collected from the north-eastern coast of New Caledonia. In defining an adamantine-type polyarsenic structure for this compound, deceptively simple NMR spectra were complemented by extensive mass spectral analysis. However, it was only the synthesis of a model compound that provided the basis to discriminate structure 4 from other spectrally compatible structures for arsenicin A; to this end, a comparative ab initio simulation of IR spectra for the natural and the synthetic compounds was decisive. Arsenicin A is endowed with potent bactericidal and fungicidal activities on human pathogenic strains. All this may revive pharmacological interest in arsenic compounds while prompting us to rethink the arsenic cycle in nature.

Algorithms↗

Cytologic features of the nested variant of urothelial carcinoma: a study of seven cases.

BACKGROUND: The nested variant of urothelial carcinoma (NVUC) is a recently described rare variant of urothelial carcinoma with deceptively bland morphologic findings, although it does display aggressive behavior. To the authors' knowledge there is no previous report of cytologic findings in urine specimens from patients with NVUC. METHODS: Urine specimens from patients with histologically confirmed NVUC were reviewed. The specimens evaluated included urine specimens obtained concurrently with or up to 1 month preceding the patients' surgical procedure. All the specimens were analyzed for the presence of cells morphologically similar to the NVUC cells observed in the tissue sections. These cells were evaluated for the following parameters: number of neoplastic cells; cellular arrangement; cell size and shape; cell borders; and cytoplasmic, nuclear, and nucleolar features. RESULTS: Thirteen urine specimens from 7 patients were included in the current study. The authors were able to identify cells that were similar morphologically to the cells present in the nests of NVUC in all cytologic specimens. The neoplastic cells for the most part were medium-sized, round or polygonal, with abundant, dense, slightly granular basophilic cytoplasm and well defined cell borders. The nuclear/cytoplasmic ratio was increased, the nuclear membranes had irregular contours, and the nuclei contained coarse chromatin with occasional prominent nucleoli. CONCLUSIONS: The cytologic features of NVUC are subtle but distinct. A primary diagnosis of NVUC in urine specimens is not recommended in view of the subtleness of the findings. Nonetheless, the presence of cells with the features described earlier should warrant a cystoscopic examination with histologic confirmation in a patient with a previous history of NVUC.

Aged↗