Ethical issues for the consultant in the general hospital

Medical practice has changed dramatically in the past 50 years since psychiatry first made inroads into the general hospital setting. The image of the wise, gentleman-psychiatrist in a tweed jacket, spreading pearls of wisdom to a train of eager students and house-officers has been gradually replaced by that of a harried consultant being summoned for triage and tranquilization. In her quest to be all things to all people, the consultation-liaison psychiatrist has to confront many an ethical dilemma. This article highlights some familiar conflicts and attempts to achieve resolution.     

Quantitative studies of the evolution of the thalamus in primates

A quantitative study of the thalamus and metathalamus has been carried out on brains of six different primate species. The allometric formula devised by Stephan, Bauchot and Andy (1970) has been slightly modified as two steps have been utilized in order to attain the required magnification of the final photomicrograph (a positive print, as opposed to Stephan et al's negative print). The thalamic and metathalamic structures are divided on the basis of their developmental stages into two groups--paleothalamus and neothalamus, so that their proportions to each other in primate phylogeny can be estimated. The results show that the neothalamus extends the paleothalamus by two-thirds (2/3rds) in Tupaia and by more than three-quarters (3/4ths) in Cercopithecus. Of all the thalamic groups, the dorsolateral thalamic nuclear group is most dominant in all primate species, except Tupaia, where the ventrolateral thalamic nuclei are larger than all other nuclei. The pulvinar is the most dominant nucleus in all species except Tupaia. These quantitative results conform, in most places, with the observations of other researchers, while they do not agree much with the qualitative observations of the thalamus in the same species (Simmons 1974). How this study has a bearing on the phylogenetic positions of the Tupaioidea and the Tarsioidea in the Primate Order, is briefly discussed.     

Vascular parkinsonism: a review of the precision and frequency of the diagnosis.

Over the past century vascular parkinsonism (VP) has been established, dismissed and recently re-established as a possible clinical entity. We review the clinical features that have been proposed to suggest the diagnosis and explore how precisely VP has been defined on the basis of clinical, as well as radiological and pathological grounds. Estimates of the frequency of this condition have been based on population-based incidence and prevalence studies and also using case series of all types or parkinsonism. We performed a systematic search for all of these published studies and present their estimates of frequency. We conclude that the wide variations in these estimates may be largely explicable by variation in case definition. When studies are limited to those with either imaging or pathological support for the diagnosis, all but one estimate that 3-6% of all cases of parkinsonism have a vascular cause. In addition, features of parkinsonism have been seen in up to 38% of lacunar stroke patients at 1 year. On the basis of this appreciably high frequency, and with consideration of the implications for clinician and scientist, we suggest that VP needs to be recognised as an important clinical diagnosis, and includes a spectrum of distinct pathophysiological entities.     

Pseudobulbar crying induced by stimulation in the region of the subthalamic nucleus

We describe a case of pseudobulbar crying associated with deep brain stimulation (DBS) in the region of the subthalamic nucleus (STN). Patients with pseudobulbar crying show no other evidence of subjective feelings of depression such as dysphoria, anhedonia, or vegetative signs. This may be accompanied by other symptoms of pseudobulbar palsy and has been reported to occur with ischaemic or structural lesions in both cortical and subcortical regions of the brain. Although depression has been observed to result from DBS in the region of the STN, pseudobulbar crying has not been reported. A single patient who reported the symptoms of pseudobulbar crying after placement of an STN DBS was tested in the off DBS and on DBS conditions. The patient was tested using all four DBS lead contacts and the observations and results of the examiners were recorded. The Geriatric Depression Scale was used to evaluate for depression in all of the conditions. The patient exhibited pseudobulbar crying when on monopolar stimulation at all four lead contacts. The pseudobulbar crying resolved off stimulation. This case describes another type of affective change that may be associated with stimulation in the region of or within the STN. Clinicians should be aware of this potential complication, the importance of differentiating it from stimulation induced depression, and its response to a serotonin reuptake inhibitor, such as sertraline.     

Evolutionary thinking in the history of the comparative psychology of learning

Darwin's theory of evolution initially inspired researchers to search for intelligence in animals. The early work was dominated by the assumption that intelligence is qualitatively the same in all species, and that it is meaningful to compare all species in the same situation or situations. This assumption persisted through the "learning theory" era, even when interest had faded in species comparisons. Even today there has not yet been an adequate test of the assumption that intelligence is qualitatively the same across species and situations. Interest has returned, however, to a second implication of evolution: We should expect to find not only similarities among species, but also divergences and adaptation to specific problems. Some speculations are offered regarding implications for human intelligence.     

Motor function and disability in the dementias

Epidemiological and neuropathological series have identified three predominant dementing processes; Alzheimer's disease (AD), vascular dementia (VaD) and dementia associated with Lewy bodies (termed Parkinson's disease dementia (PDD) in this paper). While each has its own distinguishing features and by definition all impact upon day to day functioning, no random community derived sample has examined clinical features as defined by gait and balance abnormalities and compared disability ratings of the three dementias simultaneously. Six hundred and forty-seven community dwelling subjects participated in the Sydney Older Persons Study and of these 537 participated in a medical assessment. Of these 537,482 informants rated disability. Gait and balance abnormalities of the three major dementias were identified and the association of the dementias with disability examined. The three major dementias showed evidence of both slowing and ataxia in gait and balance tests. This was maximal in those with PDD. Similarly, all showed evidence of disability that was maximal in those with PDD. In conclusion, this study has identified that gait abnormalities are present in all three dementias to a varying degree. It is hypothesised that the varying levels of disability observed are a consequence of the varying levels of motor impairment, resulting in greater levels of disability in those with PDD.     

Expression of the hexose transporters GLUT1 and GLUT2 during the early development of the human brain

We used immunohistochemistry with anti-glucose transporter antibodies to document the presence of facilitative hexose transporters in the fetal human brain. GLUT1 is expressed in all regions of the fetal brain from ages 10 to 21 weeks. GLUT1 was present in the endothelial cells of the brain capillaries, the epithelial cells of the choroid plexus and neurons. High expression of GLUT2 was observed in the granular layer of the cerebellum in brains 21 weeks old, but GLUT2 immunoreactivity was absent at earlier stages. GLUT3 and GLUT4 immunoreactivities were absent at all stages studied. GLUT5 immunoreactivity was evident only in the cerebellar region of 21-week old fetal brains. We conclude that GLUT1 plays a fundamental role in early human brain development. The data also suggest that the cerebellum of the developing brain has the capacity to transport fructose, a substrate that has not been previously identified as a source of metabolic energy in the adult human brain.     

Mitochondrial myopathies and the role of the pathologist in the molecular era

Mitochondrial encephalomyopathies are under increasing consideration in the differential diagnosis of diverse metabolic diseases from infancy to late adulthood. This is to be expected considering the vital importance of mitochondria to cellular respiration in all eukaryotes. the vulnerability of the mitochondrial genome to injury, and the expanding appreciation of the role of mitochondria as a common denominator in cell death in ischemia/anoxia, sepsis, and neurodegenerative diseases. Primary disease of the mitochondrial respiratory chain is estimated to occur with an incidence of between 6 and 16/100,000 individuals. Virtually all tissues have been shown to be involved in diverse mitochondriopathies, but none is more appropriate for diagnosis in most cases than skeletal muscle. The conventional histological and ultrastructural diagnosis of mitochondrial disease in muscle has been increasingly supplanted by the biochemical assessment of respiratory chain enzyme deficiencies and definitive genetic diagnosis. The use of such techniques has afforded a greater understanding for the relative lack of specificity of both light and electron microscopic observations. A review of the current situation by placing muscle pathology in the context of biochemical and genetic diagnosis serves as a paradigm for the role of the pathologist in the molecular era.     

The place of family therapy in the treatment of anorexia nervosa

There has been widespread, uncritical support for family therapy as the treatment of choice for all anorexia nervosa patients since Minuchin's report in 1976, but recent research has not been able to validate Minuchin's theories about the functioning of anorexia nervosa families. In the only controlled trial to date, the efficacy of family therapy was found to be superior to that of individual therapy, but only in younger patients. Selection factors for family therapy in the treatment of anorexia nervosa are illustrated by a report on 23 consecutive referrals to an eating disorder clinic. Although knowledge of the patient's family was an essential part of the assessment for all patients, and nuclear family sessions were considered to be highly desirable for all patients, in only six instances was nuclear family therapy a major component of treatment. These patients were mainly younger, had a recent onset of illness and lived in an intact nuclear family with co-operative parents.     

Shunting to the cranial venous sinus using the SinuShunt

Introduction A new shunting principle taking advantage of the knowledge of normal CSF dynamics has been developed. Experience and outcome The shunt has been used in more than 150 patients. The final version has shown a stable function in 45 patients. The physiological shunting principle has an expected and immediate clinical effect. We have not seen any over-drainage and any symptoms or signs of thrombosis or occlusion of the sinus. The ventricular system decreases only slightly. The shunt has been used in children and adults and in all types of hydrocephalus. The shunt can be implanted using local anaesthesia. The implantation in the transverse sinus has proven to be simple and safe.     

Electroconvulsive therapy in the Nordic countries, 1977-1987.

In 1977 a questionnaire was sent to all psychiatric departments in the Nordic countries: Sweden, Norway, Denmark, Finland and Iceland, concerning indications for electroconvulsive therapy (ECT) and the use of unilateral and bilateral treatment, respectively. The inquiry was repeated in 1987 and the answers compared with those obtained in 1977. In addition, the answers from Denmark were compared with previously performed inquiries. The use of exclusively unilateral treatment (U) and of both unilateral and bilateral treatment (UB) has increased in most of the countries and exclusively bilateral treatment (B) has decreased drastically. In Denmark the situation has not changed for ECT in endogenous depression and acute delirium, and the use in reactive psychosis, mania and schizophrenia decreased somewhat during the 1970s and then again stabilized or increased during the 1980s. Nearly all departments in the Nordic countries used ECT in endogenous depression in 1977 and were still doing it in 1987. In mania, about 50% of all departments have found ECT indicated occasionally or exceptionally both in 1977 and 1987. Manic-depressive mixed states have been regarded as an indication in somewhat more than two thirds of departments, increasing during the period. The use of ECT in schizophrenia has been rare and somewhat decreasing, but still about half of the departments apply it once in a while. In reactive psychosis the use of ECT decreased slightly, but in 1987 it was still in use for this indication in about 50% of all departments. In acute delirium there has been an overall increase in the use of ECT.(ABSTRACT TRUNCATED AT 250 WORDS)     

Role of angioplasty in the treatment of symptomatic vascular spasm occurring in the post-operative course of intracranial ruptured aneurysms

Angioplasty of vascular spasm (VS), related to subarachnoid hemorrhage (SAH) has been recently introduced to the medical field. The authors report 5 cases treated by this mean in the postoperative period. These patients were all symptomatic from their VS inspite of early surgery and of the preventive treatment by Nimodipine. In all cases, obtained increase in the caliber of the spastic vessels was followed by a rapid clinical improvement coupled with a significant decline of the flow rates as confirmed by transcranial Doppler (TCD). No recurrence of VS has been observed. This technique appears quite effective provided that it is performed as early as the clinical symptoms come out in correlation with important acceleration of flow rates on TCD.     

From whence psychiatry? (contribution of the gentle revolution)

Every ideology--when it has absolute rule in society--tries to proclaim its infallibility and to eliminate even mere indications of competition by all possible means of its power. This has a very deleterious effect on the thinking of people, on the overall development of human personality. This deformation has also a negative impact on the psychotherapeutic relation example: in addition to depriving the psychotherapeutic repertoire, in certain situations it may have a iatrogenic effect on the patient.     

The basic uniformity in structure of the neocortex

The number of neuronal cell bodies has been counted in a narrow strip (30 micrometers) through the depth of the neocortex in several different functional areas (motor, somatic sensory, area 17, frontal, parietal and temporal and in many species (mouse, rat, cat, monkey and man). With the exception of area 17 of the visual cortex in a number of primates the same absolute number (congruent to 110) of neurons has been found in all areas and in all species. In the binocular part of area 17 of the primates there are approximately 2.5 times more neurons. Thus in mammalian evolution the area of the neocortex increases in larger brains but the number of neurons through the depth remains constant, except in area 17 of primates. From these and other findings it is suggested that the intrinsic structure of the neocortex is basically more uniform than has been thought and that differences in cytoarchitecture and function reflect differences in connections.     

Application of telemedicine in a pain clinic: the changing face of medical practice

Telemedicine systems aim to provide quality health care services to persons whose access is otherwise restricted by geography and environment. The military medical department has a unique mission to provide all medical care for the battlefields and peacekeeping missions anywhere in the world. In addition, the medical department has to ensure the health of all soldiers, family members, and retirees during peacetime. Hospital closures coupled with a decreased number of military physicians have left many health care beneficiaries without readily available specialty care. They face long waiting lists or incur high out-of-pocket expenses in order to see medical specialists. As a result of the establishment of a virtual Telepain clinic, 56,400 miles were saved in patient and clinician travel. Use of technologies in the emerging field of telemedicine has lead to the creation of numerous military and civilian medical applications such as virtual dermatology, virtual psychiatry, virtual cardiology, virtual nuclear medicine/radiology, virtual pharmacology, and in future, virtual dentistry and ophthalmology.     

Uniting the family of psychiatric nurses: commonalities and divergences in the nursing lives we lead

We have created a new column that will focus on the state of psychiatric nursing around the world and on the increasingly important need for all of us, the family of psychiatric nurses, to begin to explore more deeply, and strengthen in more focused ways, the ties that bind all of us. We begin with an article that presents an international perspective on psychiatric illness and mental health promotion and ends by identifying common concerns often shared by the world's psychiatric nurses. Susan McCabe has a unique ability to blend the hard-core facts with a compassionate and intelligent point of view that is compelling and understandable. She is currently an associate professor at the Fay W. Whitney School of Nursing, University of Wyoming. She is an international speaker who presented at many international venues including the Sigma Theta Tau International Nursing Research Conference in the Virgin Islands in 2003 and the International Conference for Mental Health Nurses in Malta in 2002, a gathering that explored and discussed global issues of mental illness and psychiatric nursing. She is also frequently a keynote speaker or presenter at numerous psychiatric nursing conferences and has published extensively in several refereed journals and book chapters. She has expressed a deep desire for other psychiatric nurses to add their voices to hers and to comment and dialogue about our practice lives via the journal.     

On the sensitivity of the human brain to magnetic fields: Evocation of epileptiform activity

Evocation of epileptiform activity by DC magnetic fields of between 0.9 and 1.8 millitesla (mT) has been demonstrated in 6 epileptic patients undergoing presurgical evaluation. The activity was monitored by electroencephalography (EEG) recording from both electrodes attached to the scalp as well as from intracranial electrodes inserted via the foramen ovale. Epileptiform activity evoked by the magnetic field application was distinguished from background levels by comparing the number of epileptfform discharges in the 10-s intervals before and after field applications. In nearly all cases, a delay of up to several seconds was observed between the application of the magnetic field and the onset of epileptiform firing. Removal of the field also appeared to cause firing in some instances, but this has not yet been investigated systematically. In all 6 patients, subsequent seizures confirmed that the epileptiform activity monitored during the experiments was originating from the primary epileptogenic zones of the patients.     

Long-term stability of the place-field activity of single units recorded from the dorsal hippocampus of freely behaving rats

Over 90% of all spontaneously active hippocampal pyramidal cells in freely moving rats signal the animal's spatial position by reliably changing their firing rate each time the animal enters a given place within an environment. This place-field activity exhibits plasticity when specific environmental variables are manipulated. Indeed, the hippocampus is perhaps best known as a system that serves as a model of neuronal plasticity. Although place-field activity has previously been examined only over relatively short experimental sessions, this behavioral correlate of hippocampal functional activity has been assumed to exhibit stability rather than plasticity in the absence of environmental changes. The present study shows that hippocampal neurons have stable place-field correlates that persist over very long periods of time. Single-unit activity was chronically recorded from the dorsal hippocampus of rats foraging repeatedly in a stable spatial environment. The location of the place fields of all units were stable over all time periods tested, for intervals up to 153 days in duration. The consistency of the information conveyed by this single-unit activity in a fixed spatial environment indicates that stability of neuronal activity may be as important as plasticity in the integrated processing of information that occurs in the hippocampus and throughout the nervous system.     

Expression of the N-methyl-D-aspartate receptor subunit R1 in the developing human hippocampus

It has been suggested that the N-methyl-D-aspartate (NMDA) receptor family plays a key role in synaptic plasticity and synaptogenesis that is essential for memory, learning, differentiation, and development. Although gene expression of these receptors has been analyzed in the experimental animal brain and in some diseases of the adult or elderly human brain, it has not been studied in the developing human brain. Using in situ hybridization, we investigated the expression of the NMDAR1 gene in the hippocampi of 16 human neonates who were between 22 and 40 weeks of gestation and had no evidence of critical episodes of brain insult at autopsy. Signals for NMDAR1 were detected ubiquitously at all developmental stages. Dense hybridization signals were uniformly detected in the granular cells of the dentate gyrus in all specimens. Stronger signals were observed in the larger-type pyramidal cells in the CA2 and CA3 regions compared with the pattern seen in the CA1 region in the smaller-type pyramidal cells. These results suggest that the NMDAR1 gene is expressed at 22 weeks and possibly occurs earlier in neuronal cell bodies of the dentate gyrus and all CA fields of Ammon's horn and that the NMDAR plays an important role in constructing neuronal networks in developing human brains.