Somatic illness in psychiatric patients

The author reviews a dozen studies conducted over a period of 40 years and shows that approximately half of a total of over 4,000 psychiatric patients had major medical illnesses. Somatic conditions were directly related to the psychiatric symptoms in 9% to 42% of the cases. Approximately half of the patients’ referring physicians had not diagnosed their physical illnesses. These findings and five brief case reports point up the need to follow a medical model on psychiatric services.     

An interpersonal model for teaching psychiatry to medical students

Many medical students and hospital physicians hold negative images of psychiatry, perhaps because of unnecessarily complex teaching models used at the undergraduate level. The interpersonal teaching model described here allows physical symptoms to be related to interpersonal relationships. This helps the practitioner detect nonpsychotic emotional illness in medical patients. With the aid of a three-question screening test, students learned to recognize emotional illness in medical patients and to arrange psychiatric consultations. Student response to the model has been positive, and students have carried the screening skills with them to other rotations.     

Mitral valve prolapse and psychiatric disorders

The authors report the prevalence of anxiety and depressive disorders in three groups of cardiac outpatients. The first group had mitral valve prolapse syndrome; the second group had been referred with chest complaints but were proven to have no cardiac disease; and the third group had been referred with innocent murmurs and were found to have no chest complaints and no cardiac disease. There was a somewhat higher prevalence of symptoms and diagnoses of depression in the chest complaint group. The findings did not support the often reported association between mitral valve prolapse syndrome and anxiety disorders.     

Mitral valve prolapse syndrome and psychological disturbance

As a group, patients with symptomatic mitral valve prolapse (MVP) have impressed a number of observers as having a high incidence of psychological disturbance. In order to test the validity of this impression, the authors compared the hospital charts of these patients with those of patients in whom MVP was found coincidentally. Presence of recorded anxiety/depression was used as the indicator of psychological disturbance. The charts of a group of patients with cardiovascular disorders who underwent the same stresses (e.g., hospitalization, angiography), but who did not have mitral valve prolapse syndrome (MVPS), were analyzed similarly to serve as controls. The results showed patients with “primary” MVPS to be significantly more likely to be perceived as anxious and/or depressed than those with “secondary” MVP or with cardiovascular disease without MVP.     

Advances in psychosomatic obstetrics and gynecology: a brief review

This article highlights some of the recent literature covering research and clinical advances in the diagnosis and treatment of women with psychoneuroendocrinologic problems, especially those connected with the menstrual cycle, pregnancy,and menopause.     

In vivo and in vitro correlates of food allergy.

Sera of 86 patients clinically sensitive to foods were tested by passive sensitization of human and/or monkey lung (127 tests) and the radioallergosorbent test (RAST) (72 tests), using whole-food antigens; the results were compared with skin (prick) testing. Results of the prick test correlated with history in 76% of cases; lung sensitization correlated with history in 37% and with prick test in 57%; and RAST correlated with history in 54% and prick test in 72%. It is concluded that a very large percentage of adverse reactions to foods are IgE-mediated. The prick test is of use in diagnosis, particularly when combined with RAST; the lung sensitization test is technically impractical and not a reliable indicator. The best diagnostic method is careful history with food challenge and withdrawal and rechallenge; the latter is safe except in patients with a history of violent reaction.     

Clinical and physiological assessment of asthmatic children treated with beclomethasone dipropionate

Forty-two perennial asthmatic children were selected for a 12-wk study using beclomethasone dipropionate. The groups included 21 steroid-dependent children (Group I and 21 patients (Group II) whose disease was of sufficient severity that corticosteropd therapy was contemplated. All children received the drug in a dose of 100 μg 4 times daily. During the study, oral prednisone was withdrawn from the steroid-dependent children while other therapy was essentially unchanged. Group II children underwent a double-blind trial, receiving beclomethasone for 6 wk and placebo for 6 wk. Objective assessment of adrenal and pulmonary function was obtained at regular intervals. For the latter, total lung capacity and its subdivisions, airways resistance, maximum expiratory flow volume, and oxygen tension, were measured in both groups. In Group II static elastic recoil was measured also. For most tests the results were statistically significant. In both groups, 18 of 21 patients demonstrated an excellent clinical response, no evidence of adrenal suppression, and improvement in pulmonary function. Forty of 42 patients were followed for another 12 wk, and 19 of each group did well. After 20–24 wk of therapy, 16% of patients harbored monilia in their oropharynx, and 1 patient had clinical monilial stomatitis. Within the limits of the time of the study, beclomethasone dipropionate appeared to provide adequate clinical control in many chronic, severe, steroid-dependent and nonsteroid-dependent asthmatic children.     

Diagnosis of food allergy by the radioallergosorbent test

The radioallergosorbent test (RAST) was positive in 52.5% of 200 sera representing 200 food hypersensitivities from 108 patients with a history of definite immediate-type reactions to foods. Corresponding prick test was performed for 170 of the sera. The latter test was positive in 70%, the RAST was positive in 52%, and either prick test or RAST was positive in 74%. It is concluded that the RAST is positive less frequently than the prick test in the diagnosis of immediate-type food allergy in clinically sensitive patients, but that the performance of both tests increases slightly the possibility of confirming the diagnosis. However, the RAST is useful for further evaluating positive prick tests with foods that do not correlate with clinical hypersensitivity.     

Beclomethasone dipropionate aerosol in perennial rhinitis

Beclomethasone dipropionate aerosol (BDA), 50 μg four times daily sprayed into each nostril, was compared with placebo in a double-blind crossover trial in 26 patients with perennial rhinitis. Patients received BDA for 3 weeks and placebo for 3 weeks; the order of administration was randomized. Response was assessed with daily symptom score cards and twice weekly measurements of nasal airway inspiratory resistance at a standard flow rate of 0.4 L/sec. Symptom score and nasal resistance during BDA treatment were significantly lower than those during placebo treatment (p < 0.02 and p < 0.05, respectively) in the third week. Eighteen of the patients expressed a preference for BDA, 6 for placebo, and 2 for neither (p < 0.05). Acceptable symptomatic improvement (moderate or marked) was achieved by 54%. Mild side effects were noted by 5 patients; these included nasal irritation and bleeding in 2, aerosol-induced sneezing in 2, and headache in 1. These side effects occurred in 3 patients who used BDA, 1 who used placebo, and 1 who used both. After a 6-mo follow-up period, in which the dose of BDA was adjusted and concurrent initial oral prednisone was administered to patients who were treatment failures, 73% of the patients obtained moderate or marked symptomatic improvement. No further side effects were noted during this time. Results in those in whom a possible allergic component could be identified were not different from those of the whole group. We conclude that BDA is a useful addition to the therapy of perennial rhinitis.     

A survey of psychotropic use in terminal cancer patients

Using data derived from the National Hospice Study, we review utilization patterns for psychotropics in the last weeks of life of terminal cancer patients served in home-based and hospital-based hospice programs, and in conventional oncologic care settings. Drug utilization was also compared by patient demographic and medical characteristics. Three percent of the patients consumed antidepressants; 2%, antihistamines; 7%, barbiturates; 16%, benzodiazepines; and 7%, neuroleptics that are not primarily antiemetic. No difference in psychotropic consumption patterns was noted across treatment settings or by sex, presence of metastatic disease, physician specialty, or physical performance level. Younger patients were significantly (P < 05) more likely to consume antiemetics.     

Human sensitization to Ganoderma antigen.

Continuous air sampling with a Hirst volumetric spore trap over 3 yr has identified basidiospores of Ganoderma applanatum, a bracket fungus, as the most numerous fungal spores in two southern Ontario locations. The particle size is small and the calculated total spore mass approximates that of the spores of Cladosporium and Alternaria. Extracts of Ganoderma applanatum bracket fungus and spores in w/v, 1:10 concentration were prepared after collection of samples of the fungus from local woods. Skin prick tests with the extracts were performed in 294 consecutive children and adults attending two chest/allergy clinics. Of these patients, 182 (61.9%) reacted to 1 or more of the common inhalant allergen extracts and 24 (8.2%) reacted to Ganoderma antigen. There was no consistent relationship between reactivity to Ganoderma antigen and any of the common inhaled allergens. IgE-dependent sensitization to Ganoderma was confirmed by the radioallergosorbent test (RAST). Rabbit antisera to Ganoderma antigen preparations did not appear to cross-react with preparations of the various clinically important allergens. The findings indicate that Ganoderma antigen is commonly encountered, can induce human sensitization, and has unique antigenicity among common allergens of clinical importance.     

Bronchial hyperreactivity to histamine and methacholine in asthmatic children after inhalation of SCH 1000 and chlorpheniramine maleate.

Nine asthmatic patients with a mean age of 14 yr received bronchial challenges with histamine and methacholine. The challenges were repeated after inhalation of 80 microgram of SCH 1000 (ipratropium bromide) and 5 mg of chlorpheniramine maleate. The provocation doses which produced a 20% fall in forced expiratory volume in 1 sec (FEV1) and the slopes of the dose-response curves were analyzed. SCH 1000 prevented methacholine-induced bronchoconstriction and chlorpheniramine prevented methacholine-induced bronchoconstriction. There was no significant change in the dose-response curve of histamine after SCH 1000 or in the dose-response curve of methacholine after chlorpheniramine. The findings indicate that the mechanisms and receptor sites involved in bronchial provocation by histamine and methacholine are distinctly different. The histamine response is unlikely to be vagally mediated because histamine-induced bronchoconstriction was not prevented by SCH 1000. Both SCH 1000 and chlorpheniramine caused significant bronchodilatation, suggesting the presence of both histamine- and vagal-dependent bronchomotor tone.     

Ollier's disease with multiple sarcomatous transformations

A 53-year-old man had the monomelic form of Ollier's disease, which resulted in deformity of the left leg. The patient was otherwise well until pain and increasing size of the left thigh led him to seek treatment. Biopsy revealed chondrosarcomatous transformation in the distal left femur. Hip disarticulation was performed. This case is unusual in that multiple foci of chondrosarcomatous transformation at various stages of development were present throughout the left femur, tibia, and fibula.     

Determinants of the response to beclomethasone aerosol at various dosage levels: A multiple regression analysis to identify clinically useful predictors

In a dose-response study of beclomethasone aerosol (BA) therapy we noted considerable variation in responsiveness of the 34 participating asthma patients. The data were analyzed by stepwise multiple regression to identify factors which favored or inhibited the response to the drug. Among the 33 variables tested, the significant determinant variables differed depending on the BA dosage. The range studied was 200, 400, 800, and 1,600 μg/day. The reliability of several sets of these criteria for predicting the results of a therapeutic trial of BA in a given patient were checked by a cross-validation method. This demonstrated 79.4% prognostic accuracy for a set of 4 clinical variables and 88.2% for a set of 6 clinical and laboratory variables. Those patients whose symptom improvement was poor, despite receiving 1,600 μg BA per day, differed from the responsive patients mainly in the greater degree of chronic obstructive lung disease (COLD) associated with asthma. On the other hand, the symptom response to this dosage of BA in this group tended to be more favorable in nonsmoking, female asthmatic patients with frequent asthma attacks but relatively little associated COLD and no recurrent mucopurulent bronchitis. We did not demonstrate important correlations for some variables reported in other studies to significantly influence BA responsiveness, e.g., associated chronic bronchitis, prednisone daily dosage or duration, the pretreatment values for air flow indices, or allergic skin test reactivity. These data indicate that a therapeutic trial of BA is likely to benefit patients with long-term asthma regardless of its pathogenetic classification or chronicity. They further suggest that a trial with high-dose BA rather than low dosage can give more accurately predictable results.     

Serum total immunoglobulin E levels in Canadian adults

A history of respiratory and allergic disorders was obtained in a white, rural population with ages 20 to 65 yr. Allergy skin testing was performed, and total IgE was measured by PRIST method. One thousand eight hundred and fourteen subjects were studied. Those subjects with positive allergic skin reactions and a history of allergic disorders and smoking were excluded to provide a reference group to derive "normal" values of total IgE. The mean level of the total IgE of this reference group was 12.1 U/ml. The upper limit of the normal range of total IgE levels was estimated at 87.3 U/ml. IgE levels did not differ between the sexes or with age in our adult population.     

Evidence that rat peripheral myelin does not contain the rat spinal cord protein (RSCP-PN)

Rat spinal cord protein (SCP) from peripheral nerves (RSCP-PN) was not detected in purified rat peripheral nerve myelin by sodium dodecyl sulfate (SDS)-polyacrylamide slab gel electrophoresis or by immunodiffusion analyses using an anti-rat SCP in peripheral nerve (RSCP-PN) serum. The slab gel electrophoretic analyses also revealed that RSCP-PN has an appreciably lower molecular size than the component of rat peripheral myelin that is identified as P₂ by its molecular size of 13,600 daltons. Thus, RSCP-PN and rat P₂ are unrelated proteins.     

Allergy to a product(s) of ethylene oxide gas: demonstration of IgE and IgG antibodies and hapten specificity.

Patient D.H., on chronic hemodialysis, developed severe allergic reactions after exposure to articles such as plastic tubing and hemodialysis supplies which had undergone cold sterilization with ethylene oxide (EO) gas. It was shown that human serum albumin (HSA) exposed to EO (EO-HSA) in the usual sterilization procedure selectively elicited positive skin tests and in vitro histamine release. It is now demonstrated that D.H. serum reacts selectively in a radioallergosorbent test (RAST) which utilizes discs coated with HSA and exposed to EO gas. In addition, D.H. serum contained IgG antibodies reactive with EO-HSA. This antibody activity was not detected in the sera of 27 normal subjects and 25 chronic hemodialysis patients. EO-HSA and ragweed RAST inhibition tests with a number of proteins in native form and after exposure to EO demonstrated the EO hapten specificity of the IgE antibody.     

Delusions of halitosis

Review of the literature on delusions of halitosis confirms their fundamentally psychogenic basis. However, assessment of six recent cases reveals some new findings, especially that all six patients complained of sensations of bad taste. In such patients, with histories of medical problems such as rhinorrhea and rhinitis, distortions in taste physiology may contribute to the delusions of bad breath.     

Studies of hypersensitivity reactions to foods in infants and children

In order to extend previous investigations of adverse reactions to foods performed at this institution, 68 children, aged 5 mo to 15 yr, were studied. All subjects reported a history of adverse reaction to ingestion of one or more of the 14 foods under study. Sixteen of 43 subjects, 3 yr of age or older, had 22 adverse reactions during 94 food challenges with one or more of the 14 foods. All reactions confirmed were to peanut or other nuts, milk, egg, and soy. Skin testing with 1:20 weight/volume concentrations of food extracts applied by the puncture technique produced a net wheal reaction 3 mm or greater in all subjects 3 yr of age or older in whom double-blind food challenges confirmed the history of adverse reaction. Thirteen of 25 children less than 3 yr of age manifested adverse reactions during 49 food challenges. Skin testing by puncture technique produced a net wheal 3 mm or greater in 9 children less than 3 yr of age in whom food challenge elicited a clinical response within 2 hr. One of 4 subjects less than 3 yr of age in whom the adverse reaction occurred more than 4 hr after food challenge exhibited a wheal to puncture skin test of 3 mm or greater. These studies suggest that at present double-blind food challenge is an indispensible tool for the unequivocal evaluation of adverse reactions to foods.     

Nonspecific bronchial reactivity in occupational asthma

The provocative concentration (PC₂₀ mg/ml) of methacholine required to produce a fall in the baseline FEV₁ by 20% was determined in 86 patients with occupational asthma due to exposure to western red cedar, California redwood, grain dust, or isocyanates. Fifty-seven patients were assessed at the time of diagnosis when they were symptomatic. Twenty-nine patients were studied after they had been removed from exposure for a period from 2 mo to 4 yr and were asymptomatic. Nine of the 57 patients with symptomatic asthma had repeat methacholine inhalation tests after removal from exposure. The results were compared with 33 normal healthy subjects, 30 patients with nonoccupational asthma, and 17 patients with nonindustrial chronic bronchitis. Patients with symptomatic occupational asthma had marked increase in bronchial reactivity similar to those with nonoccupational asthma. The degree of hyperreactivity decreased after removal from exposure and increased following re-exposure to the offending agents. There was little overlap in the range of PC₂₀ in the asthmatic compared with the nonasthmatic groups. These findings suggest nonspecific bronchial hyperreactivity is likely to be the consequence rather than the predisposing factor in occupational asthma. Methacholine inhalation test is a simple, safe, and useful procedure in the initial assessment of patients suspected to have occupational asthma before institution of time-consuming specific bronchial provocation test.