肾脏病患者糖皮质激素和免疫抑制剂治疗并发隐球菌脑膜炎的诊断和治疗

目的肾脏病患者并发隐球菌脑膜炎的临床表现和诊治。方法分析4例糖皮质激素和免疫抑制剂治疗过程中并发隐球菌脑膜炎的临床表现、误诊原因、治疗特殊性和转归。结果例1为原发性小血管炎、Ⅲ型新月体肾炎患者;隐球菌败血症用氟康唑治疗过程中并发隐球菌脑膜炎和葡萄球菌败血症。例2、3、4均为系统性红斑狼疮患者,狼疮性肾炎(LN)维持治疗期出现发热,头痛,例1和例4继发癫痫,例2复视。例2和例3分别误诊3和5个月。4例均无家鸽接触史,有多种抗生素应用史,脑脊液均发现隐球菌。抗真菌治疗5～9天后体温正常。例1:氟康唑治疗22个月,大蒜素(120～60mg)7个月,痊愈。例2两性霉素B(总量2837mg)和氟康唑17个月。例3尿毒症行腹膜透析,伏立康唑静脉输注,1月后死亡。例4两性霉素B脂质体静脉输注并伏立康唑口服。例2和例4仍在抗真菌治疗中。结论肾脏病患者激素和免疫抑制剂治疗过程中如出现不明原因的发热、头痛尤其是癫痫、复视者,警惕隐球菌脑膜炎;有效长程抗真菌治疗外,加强支持治疗和并存的其他感染治疗尤为重要。     

Plasma and gamma-globulin infusion in chronic inflammatory polyneuropathy

We treated 17 patients with chronic inflammatory polyneuropathy (CIP) with infusions of fresh-frozen plasma (FFP). Thirteen patients had a beneficial response: 12 improved considerably and one moderately. The first signs of improvement were seen within 8 days of the onset of treatment. None of these patients had had spontaneous remissions for 2 months prior to treatment, and none had received immunosuppressive medication during the plasma infusions. The treatment effect was short-lasting in 9 patients. Re-institution of the FFP infusions was always followed by improvement. The same effect could be achieved by intravenous gamma-globulin.

We conclude that infusions with FFP, of which the IgG fraction is the effective part, may induce a rapid and clinically important improvement in patients with CIP.     

Preliminary data on the metabolic brain pattern of patients with winter seasonal affective disorder.

The brain metabolic pattern of patients with winter seasonal affective disorder with and without light treatment was determined by positron emission tomography. Compared with controls, patients with seasonal affective disorder with and without light treatment had globally lower metabolic rates, relatively lower superior medial frontal cortex rates, and somewhat higher basal ganglia rates. Patients receiving light treatment had a relatively higher rate in an occipital region of interest containing the primary visual cortex. Patients without light treatment had relatively higher metabolic rates in right parietal and medial orbitofrontal cortex and lower rates in the left parietal cortex. Patients not receiving light treatment had a hemispheric metabolic asymmetry (left greater than right) for the midprefrontal cortex located 67 mm above the canthomeatal line. The right side of this region, previously found reduced in manic-depressive illness and schizophrenia, was decreased primarily in patients with seasonal affective disorder with fewer atypical depressive symptoms. These "abnormal" prefrontal and parietal cortex regions appeared highly "coupled" in the patients with seasonal affective disorder.     

Methylphenidate and Interpersonal Relationships of Children with Attention Deficit Hyperactivity Disorder

Abstract: In order to clarify the effects of methylphenidate on interpersonal relationships of children with attention deficit hyperactivity disorder (ADHD), data from sociometric tests conducted in 28 classes to which ADHD children belonged was analyzed, comparing patients who had a history of methylphenidate treatment with those who had not. It was suggested that ADHD children with a history of methylphenidate treatment had more favorable votes and fewer unfavorable ones than those without it. However, there were more isolated children among ADHD children with methylphenidate treatment than in those without it. The results are discussed in the light of previous findings in the literature and a hypothesis for methylphenidate induced isolation is proposed.     

大剂量阿司匹林联合阿托伐他汀钙对急性脑梗死患者临床疗效观察及对血栓弹力图和C反应蛋白的影响

目的 探讨急性脑梗死后第1周使用大剂量阿司匹林联合阿托伐他汀钙的临床疗效,观察血栓弹力 图（thrombelastogram,TEG）和C反应蛋白（C-reactive protein,CRP）水平的变化。 方法 采用随机分组的方法将聊城市中心医院神经内科收治的急性脑梗死患者分为两组,大剂 量组60例,对照组60例。大剂量组给予阿司匹林300 mg联合阿托伐他汀钙40 mg口服,1次/天,治 疗7 d;后改为阿司匹林100 mg联合阿托伐他汀钙20 mg口服,1次/天,治疗7 d。对照组给予阿司匹林 100 mg联合阿托伐他汀钙20 mg口服,1次/天,治疗14 d。同时,两组患者均给予相同的基础治疗,并 适当对症治疗。所有患者治疗前及治疗14 d后均进行美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale,NIHSS）评分、TEG和CRP检测。入院时行改良Rankin量表（modified Rankin scale, mRS）评分,随访3个月时进行mRS评分,评估两种治疗方案对于患者恢复情况的影响,并评估各组再 发缺血性事件发生率。 结果 ①治疗14 d后,大剂量组NIHSS评分较对照组显著降低,比较差异有显著性（P＜0.05）;两 组与治疗前相比,治疗14 d后NIHSS评分显著降低,比较差异有显著性（P＜0.05）。②两组患者治疗 14 d后,与治疗前相比,凝血反应时间（reaction time,R）、血细胞凝集块形成时间（kinetics of clot development,K）均长于治疗前,血细胞凝集块形成速率（α角）、最大血块强度（maximum intensity of blood clots,MA）均小于治疗前,比较差异有显著性（P＜0.05）;治疗14 d后,大剂量组和对照组比 较,TEG各数值接近,比较差异无显著性。③治疗14 d后两组患者CRP水平均较治疗前明显降低,比 较差异有显著性（P＜0.05）;治疗14 d后,大剂量组较对照组CRP降低更显著,比较差异有显著性（P ＜0.01）。④两组治疗前后mRS评分比较,差异有显著性（P＜0.05）;大剂量组与对照组治疗14 d后 mRS评分比较,差异有显著性（P＜0.05）。⑤3个月后随访,大剂量组有2例再发缺血性事件,占3.33%; 对照组有5例再发缺血性事件,占8.33%,两组比较,差异有显著性（P＜0.05）。 结论 急性脑梗死患者第1周给予阿司匹林300 mg联合阿托伐他汀钙40 mg治疗较常规小剂量疗效 好,值得临床推广应用。     

Inpatient psychiatric adolescents function better than expected after discharge. A follow-up study

In order to evaluate and develop an inpatient program for adolescents, a follow-up study was carried out based on interviews with 58 adolescents discharged from the inpatient unit on average 7 years before. The mental status of these patients had been poor on admission. At the time of follow-up interviews, approximately 30% of patients appeared to have normal, socially varied lives. The results were better for patients whose treatment at the unit had lasted for more than 3 months and had included psychotherapy. Roughly 10% of the patients at the time of follow-up interviews had severe problems. The prognosis was worst for the patients who needed to be transferred from the adolescent unit to adult psychiatric treatment units because of suicidal and violent behavior. Young patients with severe disturbances need an individualized, multidisciplinary treatment approach, including individual psychotherapy and vocational training. The treatment should continue uninterrupted on an outpatient basis.     

手术治疗对脑出血预后影响的探讨

目的:探讨手术治疗与非手术治疗对脑出血(ICH)预后特别是对病死率的影响。方法:比较主要采取内科治疗的ICH241例(A组)和开展手术治疗(包括微创治疗)后的ICH203例(B组)病例资料。结果:A组病死率为48.1%,明显高于B组的15.3%(P<0.005)。结论:手术疗法的开展降低了脑出血患者的病死率,改善了预后。     

Help-seeking pathways among Malay psychiatric patients

The aim of this study is to explore the help-seeking behaviour of Malay psychiatric patients. A semi-structured interview based on a standard proforma was conducted to assess help seeking process and delays for Malay psychiatric patients attending the psychiatric clinic for the first time. Help-seeking process and delays were defined. Among 134 patients evaluated in the study, 69% had visited traditional healers (bomoh) for the present illness before consulting psychiatrists. The second popular choice of treatment was medical practitioner and only a small percentage of them had consulted homeopathic practitioners and herbalists. Patients who had consulted bomohs were significantly delayed in getting psychiatric treatment compared with those who had not consulted them. Consultation of bomohs was significantly higher among married patients, those with major psychiatric illnesses and in family who believed in supernatural causes of mental illness. However, there was no significant difference in age, gender, educational status and occupation between patients who had consulted and not consulted bomoh. We concluded that majority of the Malay psychiatric patients had sought the traditional treatment prior to psychiatric consultation. The strength of social support and the belief of the patients, friends, and/or relatives in supernatural causes of mental illness were strongly associated with the rate of traditional treatment. Deep-seated cultural beliefs were major barrier to psychiatric treatment.     

Disturbances of micturition in patients with a spinal arteriovenous malformation

Neuro-urological studies were performed on 9 patients with a spinal arteriovenous malformation (S-AVM). The micturitional history revealed that all 9 patients had voiding symptoms, obstructive in 9 and irritative in 3 patients. All patients still had obstructive symptoms after treatment of S-AVM. Six of the 9 patients had a large volume of residual urine before treatment; 5 showed urinary retention. Four of the 5 patients (80%) for whom urodynamic studies were performed before treatment had micturitional dysfunction; 2 patients had detrusor hyperreflexia, 1 with detrusor external urethral sphincter dyssynergia (DSD) and 1 with a normal sphincter, 1 patient had an autonomous bladder with DSD and 1 patient had an atonic bladder with DSD. Only 1 patient had a normal bladder and sphincter. Findings of the urodynamic studies after treatment in 9 patients showed detrusor hyperreflexia in 3 patients (2 with DSD and 1 with normal sphincter), autonomous bladder in 1 patient with DSD, atonic bladder in 4 patients (2 with DSD, 1 with incompetent sphincter and 1 with normal sphincter) and normal bladder with normal sphincter in 1 patient. Lower urinary function after treatment of S-AVM was improved in 2 patients, unchanged in 4 patients and worsened in 3 patients. The above results showed 80% of S-AVM had a severe neuropathic bladder manifested mainly by disturbance of micturition. Treatment of S-AVM does not necessarily improve the lower urinary tract function.     

A Controlled Study of the Effect of Sodium Valproate on Photosensitive Epilepsy and Its Prognosis

The effect of sodium valproate on photosensitive epilepsy was studied. The range of flash rates of intermittent photic stimulation to which patients were sensitive (photosensitive range) was tested prior to treatment, and the reliability of this measure established by repeated tests on 70 patients. The photosensitive range was measured on 50 patients prior to and during treatment with sodium valproate. In 27 patients photosensitivity was abolished and in a further 12 patients photosensitivity was significantly reduced. A group of 167 patients followed without treatment did not show significant improvement over a 7 year period. Sixteen patients had drug treatment withdrawn, and in 7 months their photosensitive range had returned to its predrug level.     

Outpatient treatment of Parkinson's disease

A retrospective study of the treatment of 148 patients with severe parkinsonism is reported. After dopa preparation was introduced as a treatment for Parkinson's disease the progress of the disease has changed. More patients with first signs after 1970 had mild progression of disease compared to patients with a debut before 1970. In addition, the population with manifestations after 1970 had fewer cases of severe progression. Adverse effects of dopa treatment had been observed in 70% of the patients. After 5 years of treatment with dopa preparation, 62.1% of the patients had momentary peak-dose dyskinesia. After 2 years of treatment 14.2% of the patients had on-off effects with higher incidence after further treatment. One hundred and fifteen patients have been treated with bromocriptine, 27 patients for more than 5 years.     

Clinical significance of outcome in long-term follow-up of borderline patients at a day hospital

All borderline patients admitted at a day hospital during a 6-year period were followed up with a postal questionnaire after 3–10 years. Patients who had chosen to leave the treatment within 4 months were analyzed as a separate group, and these drop-outs and the remaining patients were compared with a group of well-adjusted people who were assumed to represent the functional norm. The patients who remained in treatment were clearly posited at a level of functioning between the norm and the drop-outs, although the variation among them was quite large. Depending on the stringency and content of the criterion of clinical significance, 25–75% of the patients remaining in treatment fell within the range of the norm group versus 20–50% of the drop-outs. The patients who had benefited most since termination had differed favorably from the other patients already at admission to treatment, but not as much as had the drop-outs. The drop-outs, however, at admission also had more ambivalent or negative attitudes towards treatment.     

Predictors of stable personality disorder diagnoses in outpatients with remitted depression

This study examined the stability of comorbid personality disorder diagnoses once an outpatient's depression remitted. The sample consisted of 75 outpatients who responded to treatment in an 8-week acute treatment phase for depression, who met criteria for remission throughout a 26-week continuation phase, and who completed a personality assessment (Structured Clinical Interview for DSM-III-R-axis II Disorders) at the beginning and at the end of each treatment phase. The authors found that after a major depressive disorder is successfully treated, personality disorder diagnoses remain stable across time during continuation treatment. Gender was the only potential predictor variable that was significant: the proportion of men who had a stable personality disorder diagnosis in cluster A or cluster B was significantly greater than the proportion of women who had a stable personality disorder diagnosis in these two clusters. Among women, those with any stable personality disorder had a significantly longer duration of the current major depressive disorder compared with those who never met criteria for any personality disorder; this was also true for women with a cluster C personality disorder diagnosis.     

Hypnotherapy and refractory irritable bowel syndrome: a single case study

The current study describes the successful administration of hypnotherapy with a subject suffering from refractory Irritable Bowel Syndrome (IBS) and Generalized Anxiety Disorder (GAD). The subject had suffered from IBS for 30 years and had unsuccessfully pursued multiple psychological treatments, both traditional and non-traditional. He was referred to the Center for Stress and Anxiety Disorders and commenced hypnotherapy directed primarily at the IBS symptoms. After 6 treatment sessions, his IBS symptomatology had improved 53%. He stopped treatment at that point and continued autohypnosis with the aid of treatment audiotapes provided by his therapist. Follow-up at 6 months indicated continued improvement (70%). A 2-year follow-up revealed an improvement of 38% in IBS symptomatology. Concurrent levels of depression and anxiety had also substantially decreased. Hypnotherapy is shown to be a viable, palatable, and enduring treatment option for an individual who had been refractory to many previous therapies.     

Effectiveness of steroid treatment in myasthenia gravis: a retrospective study

The records of 142 patients with generalized autoimmune myasthenia gravis who had been treated with steroids as the single immunosuppressive agent, collected at regular intervals, were employed for a retrospective evaluation. The effectiveness of treatment was assessed after 24 months; the data from the 6th and 12th months were also considered. After 24 months, 63.4% of the whole sample had improved (33.8% were in clinical or pharmacological remission); 13.4% were unchanged or had worsened and 22.3% had moved to a different immunosuppressive treatment. The rate of positive outcome was higher in patients over the age of 40 at disease onset.     

Epidemiology of psychiatric disorders in Finland A five-year follow-up

Summary This study reports a five-year follow-up of a random population sample consisting of 1000 persons, who initially underwent a fairly thorough psychiatric examination. The method used at the follow-up consisted of a mail inquiry, the collection of recorded information and, for a certain proportion of the subjects, a psychiatric interview. The factors studied were the prevalence and incidence of psychiatric disorders, recovery and improvement, need for treatment and utilization of treatment services in the population. The total prevalence of psychiatric disorders was 294 per 1000, and the annual incidence 15.2 per 1000. The incidence was found to be associated with certain socio-demographic variables. A need for psychiatric treatment was found in a total of 11.4% of the subjects; in addition, 18.6% were assessed as needing supportive measures. Over the five-year period psychiatric treatment had been received by a total of 18% of the subjects. The most common provider of treatment had been the general practitioner. Psychiatric hospital care during the follow-up period had been received by 3.9% of the subjects.     

The prevalence and treatment gap in epilepsy in China: an ILAE/IBE/WHO study

The authors carried out a door-to-door survey to determine the prevalence of epilepsy among 55,000 people in China. The lifetime prevalence was 7.0/1000, and 41% of all persons had never received appropriate treatment. The prevalence of active epilepsy was 4.6/1000, and 63% of people with active epilepsy had not received antiepileptic treatment in the week before the survey. Figures for the prevalence and the treatment gap were significantly higher than previous estimates.     

Patient Satisfaction and Epilepsy Surgery

Summary: This study was designed to describe patients' experience with surgical treatment of epilepsy in terms of whether it was useful or had negative effects and to assess associations between experienced utility (satisfaction), experienced negative effects (dissatisfaction), and selected objective outcome measures. An evaluation of patients' satisfaction and dissatisfaction was conducted retrospectively by questionnaires for all patients surgically treated for epilepsy in Norway between 1949 and 1988. One hundred sixteen patients (74.3%) replied. Overall, 75% of the surgically treated patients reported that treatment had been useful, and 20% reported that the treatment had negative effects. The experience of satisfaction with treatment was strongly associated with a favorable seizure outcome, more severe underlying disease, improvements in working ability, being in regular work or education postoperatively, and not having disability pensions postoperatively. The experience of dissatisfaction with treatment was significantly associated with neurologic deficit and decreased working ability. There was overall agreement between subjectively reported satisfaction with treatment and success measured objectively. The experiences of useful effects and negative effects of the operation could not be represented by a single-dimension scale. Seizure outcome played a more important role in terms of reported useful effects, and neurologic deficit played a more important role in reported negative effects. In both categories, effects on social, occupational, emotional, and behavioral aspects played an important role.     

Benzodiazepine sensitivity testing in the management of intractable seizure disorders in childhood

The use of benzodiazepine sensitivity testing in the management of 40 children with intractable seizure disorders was studied. The aetiology and clinical syndromes varied widely with myoclonic, atonic and complex absence seizures predominating. Twenty-five cases had mixed seizure disorders. There was, likewise, a wide range of EEG abnormalities. Seven cases were in non-convulsive status at the time of testing. Diazepam (0.2 mg/kg) was given slowly intravenously and its effect on the EEG was observed. In 21 cases epileptiform activity was abolished. No change was seen in 13 cases and an unusual result was seen in 3. There was a paradoxical response in 3 cases, two of these associated with clinical seizures. Only 1 child in non-convulsive status had a positive result. Following testing, 32 patients went on to long-term oral benzodiazepine treatment. Twenty-one of these patients showed subsequent clinical improvement and 16/21 (76%) had had a positive sensitivity test previously. Eleven of these patients did not improve on long-term treatment. Seven out of the 11 (64%) had had a negative sensitivity test. These results suggest that the benzodiazepine sensitivity test is of value in the long-term management of intractable seizure disorders in childhood, but also emphasise the variability and unpredictability of response to benzodiazepine treatment.