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PubMed1984

Automated and manual perimetry-a six-year overview. Special emphasis on neuro-ophthalmic problems.

Between August 1976 and September 1982, more than 34,000 manual and automated visual fields have been analyzed in the Department of Ophthalmology, University of California, Davis. Approximately 27% of these tests consisted of manual kinetic visual fields performed on the Goldmann perimeter, while 73% were conducted using automated perimetry. Automated testing alone, or a combination of automated perimetry and manual kinetic testing (Goldmann perimeter) was usually employed to monitor progression or regression of visual field loss. This paper provides an overview of two aspects of automated suprathreshold static perimetry that have not been emphasized in our previous studies: (1) methodologic difficulties and problem patients in automated suprathreshold static perimetry, and (2) examples of automated suprathreshold static perimetry in neuro-ophthalmologic patient populations.

Adult↗
PubMed1995

Automated perimetry and malingerers. Can the Humphrey be outwitted?

BACKGROUND: Through detailed strategies and sophisticated analysis, the Humphrey automated visual field analyzer attempts to indicate if visual field loss is artefactual. Can these measures be outwitted by malingerers? METHODS: The author investigated the ease with which motivated individuals (such as are malingerers) could simulate visual field defects consistent with organic neurologic disease on the Humphrey visual field analyzer. Visual field test results were analyzed for characteristic features and compared with visual field tests from patients with documented pituitary tumors. RESULTS: Volunteers, given only broad suggestions as to the visual field they were to simulate, produced consistent, convincing, neurologic-type field defects, according to textbook descriptions of such fields. These plotted fields were only distinguishable from genuine pituitary tumor Humphrey field tests, in that they more convincingly fitted the classic descriptions of visual fields seen with chiasmal compression. CONCLUSIONS: The author concludes that single routine Humphrey visual field tests do not show malingerers. An incidental finding of this study was the extent to which Humphrey visual fields from patients with genuine neurologic disease contain field defects with characteristics different from those of the (kinetic) visual field test appearances described in the textbooks.

Artifacts↗
PubMed1999

Interstrand cross-links of cisplatin induce striking distortions in DNA.

In the reaction between cellular DNA and cisplatin, different bifunctional adducts are formed including intrastrand and interstrand cross-links. The respective role of these lesions in the cytotoxicity of the drug is not yet elucidated. This paper deals with the current knowledge on cisplatin interstrand cross-links and presents results on the formation, stability and structure of these adducts. A key step in the studies of these lesions is the recent determination of solution and crystallographic structures of double-stranded oligonucleotides containing a unique interstrand cross-link. The DNA distortions induced by this adduct exhibit unprecedented features such as the location of the platinum residue in the minor groove, the extrusion of the cytosines of the cross-linked d(GpC).d(GpC) site, the bending of the helix axis towards the minor groove and a large DNA unwinding. In addition to a detailed determination of the distortions, the high resolution of the crystal structure allowed us to locate the water molecules surrounding the adduct. The possible implications of this structure for the chemical properties and the cellular processing of cisplatin interstrand cross-links are discussed.

Cisplatin↗
PubMed2002

A subgroup of malignant fibrous histiocytomas is associated with genetic changes similar to those of well-differentiated liposarcomas.

Increasing clinical and pathological evidence suggests that malignant fibrous histiocytomas (MFH) comprise a heterogeneous tumor group. In a series of 108 MFH tested by comparative genomic hybridization, we found in 22 tumors high-level coamplification of the 12q14 approximately q15 chromosome region with other loci, a genetics strongly reminiscent of what has been observed for well-differentiated liposarcomas. Nevertheless, these MFH differ from liposarcomas by a high recurrence of coamplified partners because coamplified loci were seen at 1p32 in nine cases, 6q23 in seven cases, and 12q24 in six cases. The same recurrence was observed in a series of dedifferentiated liposarcomas, but not in a series of well-differentiated liposarcomas. These observations demonstrate that a subgroup of MFH share a genetic partner very similar to that observed in liposarcomas, and suggest that the undifferentiated status of these tumors is closely related to the amplifications of specific chromosome loci.

Allelic Imbalance↗
PubMed1979

Cutaneous artifactual disease. A review, amplified by personal experience.

Cutaneous artifactual disease is part of the general syndrome of contrived disease. While classical examples are easy to recognize, it can present in unusual ways. Difficulties in recognition include the unusual doctor-patient relationship, the doctor's fear of missing organic disease, and the reality of the disease to the patient's family and the family doctor. The diagnosis depends upon finding lesions whose morphology is consistent and an emotionally immature patient, whose personality shows, or has shown, hysterical and masochistic traits. Lesions "arrive" fully developed. Once there they begin to heal, so that a continuous supply of new ones is necessary if the illness is to continue. High intelligence is compatible with the diagnosis, but a mature personality is not. The differential diagnosis is extensive. Investigations prove negative or equivocal; in the latter case, the investigator is led even further into unfamiliar territory. It is suggested that the essence of management is to keep in contact with the patient.

Burns↗
PubMed2002

Psychiatric consequences of motor vehicle accidents.

Psychiatric complaints are frequent following motor vehicle accidents and may be major predictors of persistent pain and other complaints. Outcomes are not related closely to the nature or severity of any medical injury. Psychiatric problems often are unrecognized and untreated. There is a need for more behaviorally inferred routine care, early recognition of complications, and the use of psychological and pharmacological interventions.

Accidents, Traffic↗
PubMed1998

The dissociative disorders. Rarely considered and underdiagnosed.

A wide variety of dissociative disorders, including dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, and various forms of dissociative disorder not otherwise specified. In many instances, these disorders are either underdiagnosed or misdiagnosed secondary to the clinician's mistaken belief that dissociative disorders are rare. Recent research shows that dissociative disorders may comprise 5% to 10% of psychiatric populations. This article reviews the epidemiology and clinical symptomatology of these disorders. In addition, various screening and diagnostic instruments, such as the DES, Structured Clinical Interview for Dissociative Disorders, and MMPI, are discussed.

Amnesia↗
PubMed1998

Deception and detection in psychiatric diagnosis.

Deception is ubiquitous in all communication and relationships. It can be conscious, unconscious, or both. It is present in all psychiatric diagnoses as alterations of history, symptom fabrication, symptom enhancement or minimization, and noncompliance with treatment recommendations. We are born better deceivers than we are detectors and untrained intuition may result in very unreliable discrimination. In order to improve our ability to distinguish fact from fiction, the diagnostician must attend to clues in the patient's history and physical and mental status examinations. Laboratory examination, psychological testing, and polygraphy also can be useful adjuncts in detection; however, the first step is always suspicion.

Adolescent↗
PubMed2000

Posturographic performance in patients with the potential for secondary gain.

OBJECTIVES: To determine the incidence of nonorganic sway patterns on computerized dynamic posturography (CDP) among patients with potential secondary gain compared with patients without any obvious secondary gain. METHODS: A retrospective chart review of 100 patients who underwent clinical evaluation, audiometry, electronystagmography, and CDP was undertaken. Group 1 consisted of 50 patients who were randomly selected from a group who had pending lawsuits, worker's compensation claims, or disability claims. Group 2 consisted of 50 randomly selected patients who had no pending legal status, worker's compensation claims, or disability claims. Previously published criteria for nonorganic sway patterns were then applied to each group. Statistical analysis was performed. RESULTS: The average age of group 1 patients was 43.8 years compared with 63.2 years for group 2 patients (P < 0.0001). Among group 1 patients 50% had normal audiovestibular evaluations compared with only 4% of group 2 patients (P < 0.0001). Nonorganic sway patterns were found in 76% of group 1 patients, but only in 8% of group 2 patients (P < 0.0001). CONCLUSION: Patients who have the potential for secondary gain are generally younger and have a much higher prevalence of normal audiovestibular evaluations and a much higher prevalence of nonorganic sway patterns on CDP. A high degree of clinical suspicion should be maintained when evaluating the dizzy patient who has a pending lawsuit, worker's compensation claim, or disability claim.

Adult↗
PubMed2000

Phallometric testing with sexual offenders: limits to its value.

In many settings phallometric evaluations of sexual arousal are routinely conducted with sexual offenders and these evaluation procedures also serve as research instruments. There are, however, problems with the psychometric bases of these assessments, and studies reporting their use have so many idiosyncratic features that comparisons are of dubious value. Evidence concerning the reliability and criterion validity of phallometric testing leaves a lot to be desired, although the research has suggested an important but limited value in predicting subsequent recidivism. Suggestions are made for further research and for the clinical use of phallometric assessments within more comprehensive evaluations of sexual offenders.

Adult↗
PubMed2000

Apparent symptom overreporting in combat veterans evaluated for PTSD.

Psychometric studies have consistently shown that combat veterans evaluated for posttraumatic stress disorder (PTSD) appear to overreport psychopathology as exhibited by (a) extreme and diffuse levels of psychopathology across instruments measuring different domains of mental illness, and (b) extreme elevations on the validity scale of the MMPI-MMPI-2, in a "fake-bad" direction. The phenomenon of this ubiquitous presentational style is not well understood at present. In this review we describe and delineate the assessment problem posed by this apparent symptom overreporting, and we review the literature regarding several potential explanatory factors. Finally, we address conceptual and practical issues relevant to reaching a better understanding of the phenomenon, and ultimately the clinical syndrome of combat-related PTSD, in both research and clinical settings.

Humans↗
PubMed1981

Experience with various procedures in the treatment of orbital floor fractures.

Experience gained in the treatment of 75 patients with orbital floor injuries is presented. These injuries occurred independently or in association with mid-face fractures. In fractures of the zygomatic bone and the zygomatic part of the orbit repositioning of the zygomatic bone by a traction hook is the simplest method. In recent multiple fractures of the mid-face it is most suitable to use a lamina from the anterior or medial wall of the maxillary sinus for bridging the orbital floor defect. Osteoplasty of the orbital floor using an iliac bone graft is the method of choice in the treatment of neglected blow-out fractures fo the orbital floor. In cases with recent blow-out fractures of the orbital floor the defect can be bridged by bone taken from the hip or a lamina from the anterior wall of the maxillary sinus. It is not necessary to perform intranasal antrostomy of gauze packing of the sinus.

Bone Transplantation↗
PubMed1995

Identification of low-effort patients through dynamometry.

In recent years researchers have devised a number of methods to detect patients who purposely exert low effort during grip evaluations. This study further defines the five-rung grip test introduced by Stokes and subsequently challenged by Niebuhr and Marion. New data are presented on the rapid exchange grip test. Data were collected on four groups of subjects (sincere normals, normals asked to feign weak grip, patients thought to be sincere, and patients suspected of low effort) using both tests. In calculating the standard deviation of the plotted line of the five-rung grip test, group membership (sincere or low effort) can be predicted. No statistical difference between peak scores on five-rung and rapid exchange grip tests in sincere subjects was found. A statistical difference between peak scores in the low-effort groups was shown. A model has been developed that can be used to categorize patients into low effort or sincere groups.

Adult↗
PubMed1996

Sensitivity of the Jamar Dynamometer in detecting submaximal grip effort.

Twenty-two people with no extremity disability were tested in a standard fashion using the Jamar Dynamometer to establish their maximum grip strength. Each participant was asked to grip first right-handed then left-handed three consecutive times. The directions were reexplained so that each participant would give a consistent, less than optimal effort; three trials right and three trials left were recorded. The standard deviations of each set of these trials were calculated for both right and left hands. These standard deviations were then tabulated as scores for 44 trials of 22 patients, both hands, for maximal and submaximal efforts. These scores were then compared, maximal versus submaximal, using a paired t-test. We found no statistical difference in the two groups in comparing the variability of results. Therefore, the current protocol for Jamar testing can allow a patient to make a consistently submaximal effort, resulting in a false apparent loss of grip strength.

Adult↗
PubMed1999

The difficult patient.

The term difficult patient refers to a group of patients with whom a physician may have trouble forming a normal therapeutic relationship. The care of these patients can present many ethical dilemmas, ranging from issues of patient autonomy to questions of appropriate use of resources, which the emergency physician must be prepared to handle. Encounters with these patients also challenge physicians to explore and cultivate many of the character traits and virtues necessary to being a humane, caring, and ethical practitioner.

Adult↗
PubMedDate not supplied

Extortion in the emergency department.

We present the case of a 33-yr-old female patient who, along with members of her family, attempted to extort approximately $6000.00 from our institution and her insurance company. This attempted extortion was done under the guise of a missed retained foreign body. The patient initially presented to our emergency department with a laceration to her right forearm; X-ray studies obtained after the wound had been sutured revealed no foreign body. Several days later, the patient and family members approached our administrative staff demanding recompense for metal fragments discovered in the patient's wound at another facility. Comparison of radiographs revealed that the metallic fragments were placed in the wound after she was treated and released from our emergency department, and monetary compensation was denied.

Adult↗