Cerebellar astrocytomas. Part I. Macroscopic and microscopic features

Some of the pathological features of 112 cerebellar astrocytomas seen at The Radcliffe Infirmary between 1938 and 1984 have been described. These include the following: Macroscopic appearance: Cerebellar astrocytomas, when compared to other gliomas, have an unusual tendency to become cystic. Thus, if all ages are considered only 22% are total solid tumors while the others have either a large solitary cyst or many smaller ones. Although patients with cystic tumors remain free of recurrence far longer than those with totally solid astrocytomas, the proportion of cystic and solid elements does not significantly influence the overall survival period. Moreover, the degree of tumor demarcation is not an absolute indicator of the degree of malignancy. Extent of disease: Approximately 8% of cerebellar astrocytomas infiltrate the brainstem and these cases are associated with the poorest prognosis. Supratentorial invasion is very rare and CSF dissemination is very uncommon. Only one example of the latter was recorded in the present study. It is important to note that subarachnoid spread may also occur from histologically benign tumors as well as malignant cerebellar astrocytomas. Classification by growth pattern: The classification of cerebellar astrocytomas by "growth pattern" is clearly of limited use. This is due to the presence of substantial transitional forms in both the "juvenile" and "diffuse" as well as in the "fibrillary" and "protoplasmic" classifications. Confusion also arises because of the disregard for the quantity and distribution of certain features which, in turn, limits the usefulness of the "A" and "B" type classification system. Failure to define rigorously the cell type which predominates in the "cerebral" and "diffuse" forms also creates substantial difficulties in using Ringertz' nomenclature. Further problems are caused by Zülich's "polar spongioblastomas" since cerebellar astrocytomas are not composed of primitive spongioblasts, the "polar spongioblastomas" merely representing one subtype of cerebellar astrocytoma, namely the piloid or pilocytic variety. Attempts to classify cerebellar astrocytomas in a manner which does not rely upon any specific cell type but which depends instead upon the degree of homogeneity or heterogeneity of cell growth is of limited value. Grading schemes: Although the tumors studied in the present report were not graded, previous authors have shown that "grading schemes" are of little predictive value in assessing the behavior of cerebellar astrocytomas.(ABSTRACT TRUNCATED AT 400 WORDS)     

Causes of child abuse and neglect.

This paper is a study of child abuse and neglect from the perspective of the child. Generally, the mistreatment of children was associated with "poor care" from parents, attributed mainly to immaturity, marital problems, alcohol abuse, unemployment, drug abuse and lack of money. Differences in attribution are noted between males and females, and some differences are noted by the age of the child. When factors other than the causes given by the children were taken into account, mistreatment was significantly related to family break-up, as well as long-term disinterest and lack of affection from the parents. When the children were asked for their "worst experience in life," the most common responses were "abuse" "family break-up," and for the juvenile offenders "getting charged with a crime."     

Perceived stigma in Spasmodic Torticollis.

Little is known about the "stigmatizing" effects of Spasmodic Torticollis--a condition that produces physical disfigurement. This is important in understanding the social dimensions of this disorder. This study examined the presence, the dimensions, and the degree of perceived stigma in patients with Spasmodic Torticollis. The study was completed in two stages. In the first stage, ten patients were interviewed to identify the effects of their condition on their social interactions. In the second stage, a self-rating measure of stigma and questions about the impact of the condition on the patients' lives were devised. Perceived stigma was defined as avoidance of others, avoidance by others, self-consciousness, feeling unattractive, feeling apologetic, and feeling different from others. The questionnaires were sent to one hundred patients. The majority of the patients perceived "some" or "severe" stigma. Stigma was found to affect the patients' social, private, and working lives. It is suggested that stigma in Spasmodic Torticollis needs to be considered as a parameter relevant to the clinical management of these patients.     

Census tract of residence and the use of C.M.H.C. services

Conclusion As the need grows to understand how health care can be targeted, in the relative absence of money price, to those who need it most, studies on the effects of travel distance and other measures of time price will become increasingly important. And in order to assure the equitable distribution of services it will also be important to understand how travel distance is ade facto rationing mechanism. The methods used in this investigation easily could be applied to subscribers of Health Maintenance Organizations to determine the effect of travel distance on the utilization of preventative medical services as opposed to more expensive secondary and tertiary care.Out-of-pocket payments for health care are relatively insignificant for many people for many different reasons. In order to ration scarce services and in order to plan for the implementation of health, mental health, and other human service policies it is important to understand what other factors apart from money act as prices in the demand for services. Travel distance as a surrogate for time price, as we have seen, plays a significant role in the demand for mental health services. Time has value to us; it is worth something. And time must be given up in order to attain certain things and services so that some benefit can be derived from them. This is really rather a simple notion, but one that is too often overlooked. The idea that price has to do with more than just money (which is, after all, something of man's own making) is well expressed by Adam Smith inThe Wealth of Nations where he writes: The real price of every thing, what every thing really costs to the man who wants to acquire it, is the toil and trouble of acquiring it.Stephen L. White, Ph.D. is Associate Professor of Health Policy and Management, College of Public Health, University of South Florida, 13301 North 30th Street, Tampa, FL 33612. The author is grateful to Ralph Berry, Ph.D. and Thomas G. McGuire, PhD. for comments on an earlier version of this paper. He is also grateful to the Northern Rhode Island Community Mental Health Center for access to data.     

The psychopathology of K. Jaspers and K. Schneider as a fundamental method for psychiatry.

The paper is intended to answer the question whether and to what extent the psychopathology in the direction of Karl Jaspers and Kurt Schneider is still meaningful for contemporary psychiatry. K. Schneider developed gradually his "Clinical Psychopathology", proceeding from Jaspers' 4th edition of the "General Psychopathology" (1946). The Jaspersian-Schneiderian approach, aiming more at the elucidation of the patient's own inner experiences than at the observation of behaviour, has overcome the overly objectifying psychiatry of Kraepelin. The history and bearing of Jaspersian-Schneiderian psychopathology on psychiatry, its tenets, positions and concepts, as well as findings and results obtained with the approach are outlined. Recent developments in psychiatry, underestimating or even neglecting the psychopathological approach, are in danger of resulting in a loss of psychopathological competence in research and practice. The essay shows that this psychopathology is far from over, but remains relevant for clinical and biological psychiatry and should lead now, as ever, all other special and basic sciences in psychiatry. The critical methodological reflection and the fundamental psychopathological framework, created by Jaspers and modified and adapted to the requirements of clinical psychiatry by K. Schneider, are also today practically useful and heuristically fruitful. That we need psychopathology for diagnostics, therapy and primary and secondary prevention of schizophrenic psychoses, and also for biological psychiatric research, has been demonstrated by means of a long string of contributions of the last decades. The Jaspersian-Schneiderian approach does not mean definite conclusion and codification, but leaves enough room for new developments, completing, correcting and changing many aspects of classical and present psychiatric views. In ensues that the view of European psychiatrists that we need psychopathology, according to the axiom: "First things first" (Gross and Huber 1993a, 2000a), and the call of Andreasen (Andreasen 1998) for a serious investment in training a new generation of psychiatrists in psychopathology, seem to be well founded and entirely justified.     

Transformations of consciousness. A cartography. I. The perception-hallucination continuum.

Self-awareness emerges from the evolutionary transformation of material structures into magical, mythical and mental structures of consciousness. Western varieties of conscious states may be mapped on a perception-hallucination continuum of increasing ergotropic or hyper-arousal. These levels of subcortical arousal are cortically or cognitively interpreted as normal, creative, hyperhrenic, cataleptic and ecstatic states. During increasing hyper-arousal (characterized by EEG desynchronization): (1) the variability of the EEG amplitude decreases in introverts whereas in extroverts, it increases; (2) exteroception is transformed into an experience of interoception, while willed motor activity becomes increasingly impaired and ultimately inhibited, and (3) information processing during these hallucinatory states is preferentially shifted from the speech dominant and motor-coordinating or "major" toward the nonverbal, gestalt-perceiving, the non-dominant or "minor" cortical hemisphere.     

Trigeminal neuralgia. Pathophysiology and treatment

Trigeminal neuralgia is a very peculiar disease. The pain, also known as "tic douloureux", is paroxystic and very severe. It can be triggered by a light cutaneous stimulus on a very localized spot on the face (the so-called "trigger zone"). The patient can sometimes benefit from long remissions without any treatment. With the exception of multiple sclerosis and of uncommon cases of posterior fossa tumours or other lesions impinging on the trigeminal nerve, ganglion or root, trigeminal neuralgia is considered as "idiopathic". Some benign abnormality had for long been suspected. The current opinion is now in favour of a "neurovascular conflict": an artery, most often a loop of the superior or anteroinferior cerebellar artery, has an offending contact with the trigeminal nerve root, which results in localized demyelination and ectopic triggering of neuronal discharges. This hypothesis is in agreement with the relief provided by antiepileptic drugs and is supported by recent neuroimaging data. Therapeutic options are reviewed: very efficient drugs are available but fail to provide a significant relief and/or have important side effects in many cases. Surgical alternatives are available, for which guidelines are proposed.     

Binding of anti-actin autoantibodies to platelets.

Normal platelets incubated with anti-actin autoantibodies (AAA) (from the serum of patients with chronic aggressive hepatitis) do not show binding of these antibodies as seen by indirect immunofluorescence. AAA serum does not inhibit thrombin-induced clot retraction, despite the binding of the antibodies to platelets in the clot. Similarly, AAA serum does not affect "reversible" or "irreversible" aggregation (induced by ADP, collagen or epinephrine), despite the binding of the antibodies to platelet actin under such circumstances. AAA also bind to platelets when aggregation is inhibited by EDTA. The incubation of "reversibly" aggregated platelet with AAA results in a small but definite binding of AAA to platelets. These findings suggest that during "irreversible" and/or "reversible" aggregation, changes take place at the surface of platelets which expose the antigen at the surface of the cell.     

Event-related neuronal responses in the human strio-pallido-thalamic system. II. Cognitive functions.

Multiunit activity was recorded from the strio-pallido-thalamic system in the same parkinsonian patients (as described in the previous paper) who bore gold electrodes for diagnosis and therapy. The patients voluntarily participated in various tasks designed to study neuronal correlates of cognitive functions: "odd-omissions," "short-term memory," "cued bimodal," "assessment," and "dual-stage delayed response" tasks. Preparatory-related activities were found in multiunits reacting to sensory cues. In a few multiunits these activities depended upon the specific features of the stimuli that were anticipated for evaluation. The most striking characteristic of stimulus-related activity was the suppression of the multiunit responses when the stimuli become behaviourally meaningless. The hypothesis of action programming is discussed: the loop, including the cortex, neostriatum, pallidum and appropriate parts of the thalamus, is involved in the selection of actions, thus providing the organization of sequential behaviour.     

Koro epidemics in Guangdong, China. A questionnaire survey.

Koro epidemics, characterized by panic due to fear of genital retraction, involving more than 2000 victims, mainly young men, occurred in Hainan Island and Leizhou Peninsula of Guangdong Province, China, in 1984-85 and 1987. A questionnaire survey of 214 victims of these epidemics was conducted in 1988. The survey focused on symptom manifestation, personality profile, life problems, and folk belief. The results of the "koro" group were compared with those of a "clinic" group with minor psychiatric disorder and a "control" group from the non-clinical, non-koro episode population in the epidemic area. The results revealed that the victims of the koro epidemics were characterized by low intellectual endowment and strong acceptance of koro-related folk beliefs. The results support the hypotheses that: a) a koro attack is a psychologically induced anxiety-panic condition; b) the presence of an intensive belief in the culturally related concept of koro makes the subject vulnerable to the attack; and c) social crisis or tension serves as a trigger for the occurrence of the epidemic.     

Heroin addiction. Sequential treatment employing pharmacologic supports.

A system of treatment for heroin addiction is proposed under the acronym STEPS (sequential treatment employing pharmacologic supports). Small steps characterized by decreasing narcotic-induced euphoria and increasing social rehabilitation are expected eventually to bring the addict to an abstinent and well-functioning state, if that is possible. The dichotomous assessment of "success" or "failure" is rejected in favor of the expectation of partial and temporary improvements, as with any chronic relapsing disease.     

The thought-brain relationship. New facts. New hypotheses

The close links between Thought and the brain having been amply demonstrated by the neurosciences, it is now time to draw conclusions. After having shown that the specific characteristic of thought is the self, the author underlines the impossibility of explaining the self by objective study and the consequent need to preserve for the thought its specificity in relation to Matter-Energy. After having excluded, by this statement, attitudes tending to deny explicitly or implicitly the specificity of Thought and having rejected spiritualist hypotheses as not conforming to scientific data, only two possible interpretations remain: that of the identity of Thought and Matter-Energy treats Thought as the other face of Energy, that of creation makes it necessary to admit a transformation from Energy to Thought (E = KP). The problems of thermodynamics and of the quantification of Thought thus raised are considered. Whatever the solution, it is necessary to admit that a "Universal Thought" exists. The universe is conscious of itself. The effort of cerebralisation in the evolution of species seems a mean of giving autonomy to individual thought which is necessarily included in Universal Thought.     

Delirium: phenomenology and diagnosis--a neurobiologic view.

"Delirium" is a reversible confusional state. It results from widespread but reversible interference with the function of cortical neurons, as documented by diffuse slowing on EEG and decreases in cerebral metabolic rate. Delirium can be due to impairments in neuronal metabolism, in neurotransmission (notably cholinergic), or in input from subcortical structures. Engel and Romano (1959) formulated delirium and dementia as the two poles of a spectrum of "cerebral insufficiency," with delirium resulting from reversible functional impairment and dementia from irreversible anatomic damage. So many disorders can precipitate delirium that the differential diagnosis tests every facet of one's knowledge of medicine. With aging, both normative changes in the brain and the increasing incidence of brain diseases predispose to the development of delirium. The brain damage responsible for a dementia can sensitize to the development of a superimposed delirium.     

It is always the woman who is raped.

Rape is described as an act of power that is sanctioned by literature, myth, and culture. Rape is a dire experience for women because it implies total loss of self--the woman is a function, not a person. The victim experiences total emptiness and isolation from self and society. The author believes that an effective "treatment" for the rape victim is community. Women asserting themselves by speaking out about their experience validate themselves as persons.     

Withdrawal of visual feedback improves micrographia in Parkinson's disease.

Micrographia is a common, often presenting feature of Parkinson's disease. We assessed a simple writing paradigm in 40 PD patients "off" medications, 40 different PD patients "on" medications, and 64 age- and sex-matched controls. Patients wrote "Today is a nice day" with both eyes open and eyes closed to assess the effects of visual withdrawal (eyes closure). The order (eyes open vs. eyes closed) was alternated. In the "off" medicine group, eye closure increased the writing length by 14.0 +/- 10.1% (P < 0.05) from a mean of 69.1 to 77.7 mm [range -14% to +73%]. The percentage increase was larger in the 20 subjects with the smallest baseline writing size (worse micrographia), compared to the 20 with relatively larger writing (19.5% vs. 7.9%, P < 0.05). Neither the "on" medicine group, nor the control group changed. Simple eye closure significantly increased writing size in "off" PD patients to a similar or greater amount as levodopa. This data suggests that micrographia is not a pure motor hypokinetic feature but is affected by PD similar to other superlearned tasks such as walking. Furthermore, some patients have adapted this simple eye closing strategy when writing, especially signatures.     

Psychiatry and interdisciplinary research. Value of a systems approach

Interdisciplinary research is particularly difficult, because of the different frames of reference used in the individual disciplines. Psychiatry by itself show already the complexity of the current methodological situation. A fundamental epistemological problem is posed by the unity and uniqueness of the patient as opposed to the multiple-faceted traits and experiences presented to the observer. The authors show the utility of the systems concept for solution of these difficulties. They depict the characteristics of "the systemal method", the way it is employed and its many applications in the clinic as well as in pharmacology, neurochemistry, neurophysiology and ethology. The systemal approach allows comparison and integration of data and results from various disciplines by means of the concepts "homology" and "isomorphism", and may thus contribute to progress in the study of biological psychiatry. It also makes it possible to regard the organism as an ensemble of sub-systems in interaction with its environment. Finally, because of its logicomathematical foundation, the systemal approach lends itself readily to application of computer techniques.     

Excitability of human axons.

The excitability of human axons can be studied reliably using the technique of threshold tracking, which allows the strength of a test stimulus to be adjusted by computer to activate a defined fraction of the maximal nerve or muscle action potential. The stimulus current that just evokes the target response is considered the "threshold" for that response. More useful than the resting threshold are other indices of axonal excitability derived from pairs of threshold measurements, such as refractoriness, supernormality, strength-duration time constant and "threshold electrotonus" (i.e. the changes in threshold produced by long-lasting depolarizing or hyperpolarizing current pulses). Each of these measurements depends on membrane potential and on other biophysical properties of the axons. Together they can provide new information about the pathophysiology underlying abnormalities in excitability in neuropathy.     

Retinogeniculate projections in albino and ocularly hypopigmented rats.

The retinogeniculate fiber projections were studied by degeneration methods in several strains of rats with pigmentation in their eyes and pelts ranging from the intensely pigmented self phenotype to the albino. The ipsilateral retinogeniculate input in the self, Irish, and hooded rats, and rats with "bicolor fundus" is located medially within the dorsal alteral geniculate nucleus (LGd) and is seen as a single lamina of moderately dense degeneration.     

Evaluating the competence of psychotherapists.

Pressure is increasing to develop methods for evaluating the competence of psychotherapists, not only in the field of education but also in clinical practice. The skills required of a psychotherapist have not yet been defined clearly, and are probably specific to kinds of patient and types of problem. However, there is a concensus that the capacity to establish a trusting relationship and to demonstrate concern, are essential. This relationship provides a "power-base" from which to influence the patient through a variety of elements which include "interpretation", modeling, and identification. Psychoanalysts assert that the "working through" of the transference is essential, but this is disputed by others. The evidence regarding the value of experience as a psychotherapist is unclear. Again there are conflicting reports. It appears that reasonable competence in technique can be acquired (through modeling) within the first year of training. It may be that the reason why experience does not emerge more strikingly as a positive factor, is that in the published material the more experienced psychotherapists treated the more difficult patients, and therefore the outcome of their treatment suffered. This paper touches on recent approaches at McMaster University to evaluate the competence of trainees; one by setting instructional objectives in family therapy, the other by means of a process analysis of videotaped interviews, in which residents and their supervisors participated. A single simulated patient was interviewed at two points in time, to indicate change and development in the psychotherapeutic techniques of the trainees.