Vascular parkinsonism

Abstract. The concept of vascular parkinsonism (VP) has been highly controversial since the initial paper by Critchley in 1929. This review tentatively delineates the extent of the spectrum of VP. Much confusion has arisen owing to the lack of clear definitions of parkinsonism, atypical parkinsonism and pseudoparkinsonism, which we here attempt to define. Confusion has also arisen because incidental vascular lesions occurring in true idiopathic Parkinsons disease (IPD) are up to 10 times more common than parkinsonism due to cerebrovascular disease. VP is clinically heterogeneous. Most often VP is atypical and can be separated from IPD, on the basis of the presence of additional focal signs, and the absence of typical resting tremor in the upper limbs, of true akinesia (i. e.: with decrement and fatiguing of alternating movements), and of definite benefit from levodopa. Exceptionally, VP may mimic IPD or other degenerative diseases such as progressive supranuclear palsy or corticobasal degeneration. The lesions responsible for VP are mostly basal ganglia lacunes and/or subcortical white matter vasculopathy of the Binswanger type. Rarely, a single striatal infarct, striatal cribriform cavities or ischaemic changes in the substantia nigra have been described. Vascular pseudo-parkinsonism refers to isolated gait disorders called lower body parkinsonism, frontal-type gait disorders or gait ignition failure that are reminiscent of, but distinct from, that found in IPD. The pathophysiology of VP is poorly understood. Why some patients develop parkinsonism and others do not, despite the same apparent lesion load, remains a mystery.     

Reliability of circadian heart pattern analysis in psychiatry

The assessment of circadian heart patterns represents a new methodology for documenting physiological dysregulation associated with psychiatric illness. Previous research has demonstrated abnormal heart rate patterns, especially during the bedtime interval, that are associated with depression, generalized anxiety disorder, panic disorder, and schizophrenia. These patterns are derived from heart rate data obtained while wearing an unobtrusive, two-lead heart rate monitor over a 24-hour period. To establish basic reliability, the second author blindly rated heart-monitored data from 50 subjects on two occasions, separated by an average of 6.6 weeks (range = 2.9–15.7 weeks). Subjects were classified as definitely psychiatric, probably psychiatric, borderline, broadly normal, and signature normal. The exact category agreement rate was 78%. If a one-category difference is permitted (e.g., definitely psychiatric and probably psychiatric counted as an agreement), the agreement rate was 92%. Circadian heart pattern analysis is a promising new technology in psychiatric research and warrants further investigation.     

DL-lysine-H3 uptake in “light” and “dark” neurons of the inferior olivary nucleus of euthyroid and dysthyroidal rats

Summary Uptake of DL-Lysine-H³ into light and dark cells of the rat inferior olivary nucleus was studied by radioautographiy. Uptake in light cells was higher than in dark cells and appears to be possibly related to the greater frequency of relationship with glial satellites. Dysthyroidal states were also observed to increase uptake of radioactivity which was prominently observed in hypothyroid rats. Since dark cells appear to take up less lysine than normal cells and are less frequently closely associated with glial satellites it is suggested these cells may represent a less physiologically active unit than the light cells rather than being simply artifactually produced by the procedures employed.

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Zusammenfassung Die Aufnahme von DL-Lysin-H³ in hellen und dunklen Zellen im unteren Olivenkern der Ratte wurde mit Autoradiographie beobachtet. Die Aufnahme war höher in den hellen Zellen als in den dunklen, was möglicherweise mit einer größeren Häufigkeit von Glia-Satellit-Verbindungen in Zusammenhang gebracht werden könnte. Veränderungen im hormonalen Zustand der Schilddrüse konnten auch dazu beitragen, die Aufnahme von Radioaktivität zu erhöhen, was besonders bei Ratten mit niedriger Schilddrüsenaktivität hervortrat. Da dunkle Zellen offenbar weniger Lysin aufnehmen als normale Zellen, und sie seltener mit Glia-Satelliten verbunden sind, wird angenommen, daß diese Zellen möglicherweise eine weniger aktive physiologische Einheit darstellen als die hellen Zellen und daß es sich nicht einfach um ein Kunstprodukt handelt.

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This investigation was supported in part by a PHS research grant (NB-456802) from the division of Neurological Disease and Blindness and in part by Contract NONR 4018(01), (NR 101-592), between the Office of Naval Research, Department of the Navy, and the Research Foundation of the State University of New York.     

Administrative influences on psychiatric diagnosis

Summary In order to cut expenditure on mental health care in Brazil, the national authority responsible for the financing of health care imposed in 1977 the following two restrictions on reimbursement: a) the costs for inpatient treatment under the diagnoses neurosis and alcoholism would be paid only for a maximum length of hospital stay of 30 days and b) the costs for inpatient treatment under the diagnoses oligophrenias and epilepsies would no longer be paid. We studied the effects of these administrative measures upon the yearly frequencies of diagnoses and the mean lengths of hospital stay in 27377 treatment episodes between 1975 and 1982. We found significant decreases in both variables for the above mentioned diagnoses after 1977. At the same time the frequencies of the diagnoses alcoholic psychoses, psychoses associated with other cerebral conditions and other psychoses increased significantly. These findings can probably not be attributed to true changes in morbidity, but are rather the results of changes in diagnostic habits in response to administratively imposed austerity measures.     

Styles of Case Management: The Philosophy and Practice of Case Managers

A great deal of discussion and research has gone into defining and clarifying the role of case manager (CM) for persons with severe mental illness. This three state survey examines the philosophy and activities of practicing CMs in an attempt to identify current styles of case management. A cluster analysis based on CM rankings of five CM functions suggested four styles of case management: supportive social worker, individual therapist, therapist broker, and community advocate. Overall, CMs rated supportive interventions as most important and formal psychotherapy as relatively unimportant. CM style was related to CM activity (i.e., distribution of effort). Differences between states are noted and implications for future research are discussed.     

Prevalence of known and hidden alcoholism in the revisited lundby population

Summary Using the new data from a second followup of the Lundby 1947 cohort, the aim of the present paper has been to analyze some relationships between known and hidden alcoholism in a Swedish general population sample. Information was collected by psychiatrists trough free, exploratory field interviews checked against documentary records. Alcoholism was medically defined for present purposes. Information was obtained for 98% of the 952 men surviving the cross-section date July 1, 1972. The distribution of alcoholism and other psychiatric disorders in the total population and in age subgroups was analyzed epidemiologically. The true prevalence of alcoholism in the adult men was 9.5%, comprising 7.2% known and 2.3% hidden. The proportion of hidden to known cases was 0.301 (Temperance Boards 0.871, Psychiatric Agencies 0.961, Drinking and driving offences 4.31). The main finding that about 70% of male alcoholics in Lundby appears to be known to the agencies is at variance with current views that there is an iceberg under the tip, though consistent with Rubington's suggestion that so-called hidden alcoholism is not totally but partially invisible in welfare societies.     

A comparison of five diagnostic systems for childhood schizophrenia and infantile autism

Five diagnostic systems designed to differentiate infantile autism and early childhood schizophrenia were compared by deriving scores on 44 children referred consecutively to the same clinical center. While the autistic scales devised by Rimland, Polan and Spencer, Lotter, and the British Working Party correlated significantly, the degree of correspondence (35%) indicated that several children obtained high autistic scores in one system but low scores in another. The BWP's term schizophrenia has more correspondence with the term autism used by others than with Rimland's schizophrenia. In the DeMyer-Churchill categorical system (early schizophrenia, primary autism, secondary autism, and non-psychotic subnormal), primary autism most resembles Rimland's concept of infantile autism as measured by his E-1 version. All other systems differentiate psychotic from non-psychotic children but do not distinguish any of the psychotic subgroups.This study was supported in part by Public Health Service Grant No. MH05154 and also by LaRue D. Carter Memorial Hospital, State of Indiana, Indianapolis, Ind.The authors wish to thank Dr. Bernard Rimland for providing his scoring key.     

Neuroectodermal tumors of the peripheral and the central nervous system share neuroendocrine N-CAM-related antigens with small cell lung carcinomas

Summary The current study describes the presence of neuroendocrine antigens of peripheral and central neural tumors using eight monoclonal antibodies raised to small cell lung carcinoma (SCLC), which recognize neural/neuroendocrine or neural antigens, as defined by their reaction pattern in normal tissues and tumors. At least five of them recognize different epitopes of the neural cell adhesion molecule (N-CAM). It was found that all of 12 neuroblastomas, 2 ganglioneuroblastomas and 4 ganglioneuromas as well as 23 central primitive neuroectodermal tumors, 13 astrocytomas and 4 ependymomas share neural/neuroendocrine antigens (as defined by the anti-N-CAM antibodies Moc-1,-21,-32,-52 and-191) with SCLC. The neural/neuroendocrine antigen defined by Moc-171 was also found in all peripheral tumors, but only in further differentiated central tumors. Non-N-CAM related neural antigens (as defined by Moc-51 and-172) were found only in better-differentiated peripheral and central tumors, but they could be demonstrated in all three medulloblastoma cell lines studied. In addition, the antigen defined by Moc-51 was demonstrated in an immunoblot of a neuroblastoma cell line. Antibodies recognizing epithelia antigens of SCLC and other epithelia and their tumors (Moc-31 and-181) were non-reactive. It was concluded that these findings give further support for a relation between neural and neuroendocrine tumors and that some of the antibodies may be useful for the detection of differentiation in neural tumors. Antibodies with an epithelia recognition pattern may serve to distinguish neural from neuroendocrine tumors.Supported by NIH grant CA 36245 W.M.M. was a Fullbright scholar     

Cranial burst fracture in infants: acute recognition and management

In the past, the diagnosis of growing skull fracture or diastatic fracture has included a subset of injuries better referred to as cranial burst fracture. Cranial burst fracture, typically associated with severe injury in infants less than 1 year of age, is a closed, widely diastatic skull fracture accompanied by acute cerebral extrusion outside the calvarium. We treated 11 such infants at the LeBonheur Children's Medical Center and 2 at the Children's National Medical Center from January 1986 through December 1994. Infants ranged in age from 1 to 17 months, with an average age of 5.7 months. All presented with marked scalp swelling and a Glasgow Coma Scale score of 10 or less. Twelve had a history consistent with severe injury (motor vehicle accident, 7, abuse 5). The cause of injury in one patient remains unproven. Surgery (reduction of herniated cerebral tissue, repair of large dural laceration, and cranioplasty) was usually performed within 10 days of injury, a time period long enough to assure hemodynamic stability and resolution of acute cerebral swelling, yet sufficiently brief to avoid the chronic changes (scarring, parasitization of scalp vessels by damaged cortex) associated with a growing skull fracture. Prompt repair of cranial burst fracture may prevent ongoing brain injury such as has been neuropathologically demonstrated in patients with growing skull fracture. Magnetic resonance imaging establishes the diagnosis of cranial burst fracture in equivocal cases, rendering unnecessary a waiting period to see if scalp swelling resolves. Our experience, together with information in the neuropathological and neurosurgicla literature, suggests that cranial burst fracture is associated with severe trauma, requires expeditious treatment, and has been underdiagnosed in the past, leading to growing skull fracture, a condition requiring more extensive surgery.     

The assaultive psychiatric patient

In the light of rather widespread aggressive feelings and frequently poor controls among psychiatrically hospitalized patients, the number of serious assaults and even incidents is remarkably low. Nevertheless, there is an indisputable need for institutions to put the same kind of effort into identifying cases calling for Violence Precautions as has always obtained with regard to Suicide Precautions.     

Electrophysiological evidence for visuocognitive dysfunction in younger non caucasian patients with Parkinson's disease

Summary A study of primary (VEPs) and cognitive (ERPs) visual evoked potentials was carried out in a group of non-demented Afro-American Parkinson's disease (PD) patients. Current studies suggest that differences exist in the clinical manifestations of PD in Caucasian and non-Caucasian populations. Two horizontal sinusoidal gratings differing in spatial frequency, i.e., 1 and 4 cycles per degree (cpd), were presented in an oddball paradigm to 17 patients with PD and 17 age-matched control subjects. While the 1 cpd stimulus, is not expected to reveal retinal dopaminergic deficency, but only visuocognitive deficits, the 4 cpd may give direct information of both retinal and cognitive visual deficits. We measured the latencies and amplitudes of N70, P100 and P300 components, and derived the normalized measures of P300-N70 latency difference (Central Processing Time-CPT70), the P300-P100 latency difference (CPT100) and the P300 amplitude responses normalized to either N70 and P100 amplitude (Amplitude Ratios AR70 and AR100). Our results do show that cognitive electrophysiological deficits in younger PD patients exist in non-Caucasians, perhaps to an even greater degree than in Caucasians, and confirm that absolute and normalized ERP amplitude and latency abnormalities are a distinguishing feature of younger PD patients from controls. In particular P300 measures are abnormal for 1 cpd pattern. A negative correlation exists between P300 amplitude and the motor score. By comparing the results for 1 and 4 cpd stimuli it can be concluded that primary and cognitive visual abnormalities are independently affected in PD, implying that visuo-cognitive abnormalities are not passively determined by retinal dopaminergic deficiency.     

Semantic amnesia without dementia: documentation of a case

We described the case of a patient affected by a progressive semantic memory disorder associated with prevalent temporal lobe atrophy. This deficit seems to be pure in the sense that it has not been found to overlap with other cognitive deficits (intellectual, linguistic, perceptual, visuo-spatial etc.) for a long time. Furthermore, despite his impaired semantic knowledge, the autobiographical memory of the patient was largely intact. This case therefore represents a form of semantic amnesia without dementia, and supports the hypothesis that there is a partial distinction between semantic and episodic memory.

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Sommario Descriviamo il caso di un paziente con atrofia bilaterale (prevalentemente temporale) affetto da un deficit progressivo semantico. Non si evidenziarono (almeno per lungo tempo) altri deficit cognitivi e la memoria autobiografica/episodica, in contrasto a quella semantica, risultò sufficientemente conservata. Il caso rappresenta, perciò, una forma di amnesia semantica in assenza di deterioramento cognitivo e sostiene l'ipotesi della distinzione tra memoria semantica ed episodica.

     

Amyotrophic cerebellar hypoplasia

Summary Lower motor neuron degeneration, cerebellar hypoplasia, atrophy of pons, olives, and cerebellum, sclerosis of thalamus and pallidum, and deficient myelination were found in a 2-months-old baby with laryngeal paralysis, mental retardation, progressive amyotrophy, and slow nerve conduction velocity. Such changes seem characteristic of an unusual syndrome previously referred to as cerebellar hypoplasia in Werdnig-Hoffmann disease, or anterior horn cell disease with pontocerebellar hypoplasia. Although the pathologic changes in lower motor neurons are indistinguishable from those in other cases of infantile spinal muscular atrophy, the consistent reproducibility of a complex pathologic pattern suggests that this is probably a manifestation of a separate disease process. The term amyotrophic cerebellar hypoplasia (ACH) is a convenient designation for the syndrome.Supported in part by National Institutes of Health grant no. RR75     

Enlarging skull fractures in children

Large skull fractures are conventionally followed radiographically until healing occurs. Fractures which enlarge or remain unhealed are commonly termed leptomeningeal cysts or growing skull fractures. This study of ten children with this injury and a review of the literature shows that a true leptomeningeal cyst is seldom present and that skull fractures do not grow. Moreover, careful history-taking and physical examination will correctly identify all enlarging or unhealed skull fractures of childhood without the need for plain radiographs or computed tomography of the skull.     

Obsessive-Compulsive Disorder in Popular Magazines

To examine what the general public is learning about Obsessive-Compulsive Disorder (OCD) through popular magazines, all articles listed in the Reader's Guide to Periodical Literature under the topic headings of obsessive-compulsive behavior or obsessive-compulsive disorder between 1983 and 1997 were read and rated. Only 31 of the 107 articles under these headings dealt explicitly with OCD, and these were found to be reasonably accurate in their presentations of symptoms, causes, and treatments. Many of the other articles under the target headings, however, focused on incidents of stalking of famous people by obsessed fans. The implications of the content patterns of these articles for understanding and misunderstanding of OCD are discussed.     

Serum creatine kinase B subunit levels in neurogenic atrophies

Summary This study is an attempt to determine the creatine kinase B (CK-B) subunit levels in neurogenic atrophies. A group of 69 patients was studied and the results were compared with those in a group of 32 patients with muscle disease. The results showed that the CK-B levels are considerably higher in patients with amyotrophic lateral sclerosis (P<0.001) and peroneal muscular atrophy (P<0.001). Further studies in the various subgroups of neurogenic atrophies showed that, regardless of the nosological entity, the CK-B activity is considerably higher: (1) in the widespread as opposed to limited forms (P<0.001); (2) in the chronic than in the acute neurogenic atrophies (P<0.001); and (3) in the active as opposed to residual forms (P<0.02). It is suggested that the increase of CK-B in neurogenic atrophies is a strong indication of an active regeneration process in the denervated muscle.     

Willingness of Nigerian University students to accept psychological treatment

Summary This study assesses the effects of the stated purpose of treatment on University students' willingness to be involved in treatment for emotional problems. The study involved 26 male Nigerian undergraduate students evidencing severe examination anxiety. These students were randomly assigned to one of three groups with different treatment goals (a mind change group, a behaviour change group, and a No Goal group). All subjects received the same treatment — a combination of systematic desensitization and a process of gradual habituation. Differences between the groups in willingness to participate in treatment were assessed on the basis of the actual frequency of attendance at scheduled treatment sessions by subjects in each group. The results indicated that the subjects in the behaviour change group attended significantly more treatment sessions than the subjects in the other two groups. This finding suggests the need for awareness of the possible effects of the stated or implied treatment goals on the acceptance of psychological treatment among university-level educated clients.     

“On-off” phenomenon in Parkinson's disease: Correlation to the concentration of dopa in plasma

Summary To investigate the relation between on-off fluctuations in symptomatology and bioavailability of dopa in patients with Parkinson's disease, five Parkinsonian patients with pronounced on-off symptoms were studied. Continuously during the study the degree of disability in the patients was registered. Every one hour, and in addition, whenever there was a change from on to off or vice versa, a blood sample was collected for dopa determination. Since dopa is transported from plasma into the brain by a saturable carrier for which it has to compete with endogenous large neutral amino acids (LNAA), the concentrations of these competitors were measured too.In four of the patients there were considerable oscillations in the plasma dopa concentration during the day; in one of these patients the highest value was as much as 12 times higher than the lowest value. These dramatic fluctuations in the absolute concentration of dopa in plasma had a major influence on the relative dopa concentrations (calculated as the ratio dopa/sum of LNAA) as the fluctuations in the concentrations of LNAA in plasma were much less pronounced. Consequently, the absolute and the relative concentrations of dopa in plasma were highly parallelled.In four of the five patients on-periods began within one hour after a peak in the concentration of dopa in plasma and in the fifth patient five out of seven on-periods were preceded by a rise in plasma dopa concentration within the same time interval.From the present data it could be concluded that the on-off phenomenon in Parkinson's disease, at least partly, is due to oscillations in the concentration of dopa in plasma. A reduction in the variations of the concentration of dopa in plasma seems to be necessary to overcome the on-off problem. The introduction of a slow release preparation of dopa is therefore urgently warranted. The concentration of LNAA in plasma must, however, also be considered in this context.     

Histochemical and electron microscopic observations on “onion bulb” formations in a case of hypertrophic neuritis of 25 years duration with onset in childhood

Summary Histochemical and electron microscopic data are presented from a patient with hypertrophic neuritis of 25 years duration with onset in childhood. The present observations and those of recent investigators form the basis of a discussion of various pathogenetic hypotheses for onion bulb structures in the nerves from patients with hypertrophic neuritis. It is concluded that the onion bulb lesion is a nonspecific manifestation of chronic segmental demyelinization resulting from a primary or acquired abnormality of Schwann cells.

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Zusammenfassung Histochemische und elektronenoptische Befunde eines Patienten mit hypertrophischer Neuritis von 25 Jahren Dauer mit Beginn der Erkrankung in der Kindheit werden mitgeteilt. Die erhobenen Befunde sowie andere jüngste Beobachtungen bilden die Grundlage einer Diskussion der verschiedenen pathogenetischen Hypothesen der Zwiebelschalen-Strukturen in den Nerven von Patienten mit hypertrophischer Neuritis. Die Zwiebelschalenbildung wird als unspezifische Manifestation einer chronischen segmentalen Entmarkung infolge primärer oder erworbener Anomalie der Schwann-Zellen interpretiert.

     

Intelligence and temperament as protective factors for mental health. A cross-sectional and prospective epidemiological study

The Sjöbring system of personality dimensions measuring intellectual capacity, activity, impulsivity and sociability was used to study possible salutogenic (i.e. causes of health) effects. The study comprised 590 subjects investigated in 1947, 1957, 1972 and 1988–1989 in the Lundby project, an epidemiological study in Sweden. Psychiatric diagnoses were made in 1947, 1957 and 1972. Mental health was estimated in 1988–1989 using the concept love well, work well, play well and expect well. The Sjöbring dimensions were clinically assessed in 1972. Both in the concurrent study in 1972 and in the prospective study in 1988–1989 super capacity (high intellectual function), super validity (high activity level) and super solidity (low impulsivity) were statistically associated with lower frequencies of certain psychiatric diagnoses and a higher frequency of positive mental health. These variables are proposed to increase coping capacity, and therefore increase stress resilience.