Depression in late life: psychiatric-medical comorbidity

The links between late-life depression and the medical comorbidities that are often associated with it can be divided into two paths. The path from medical illness to depression reflects general mechanisms related to stress, disability, and loss, as well as more specific physiological mechanisms, including those related to subclinical cerebrovascular disease, adverse drug effects, and endocrine/metabolic effects. Similarly the path from depression to medical illness includes general mechanisms related to self-neglect, decreased adherence to medical treatments, maladaptive health-related behaviors, and, possibly, more specific physiological mechanisms including those related to altered endocrine and autonomic functions, in the clinical context, these two paths can interact to constitute a vicious cycle. With further research, it should be possible to translate current understanding in these areas into advances in both basic knowledge and treatments that could initiate virtuous cycles with beneficial effects for both menial and physical health.     

A review of the effect of traumatic brain injury on the human sexual response

A human sexual response format was used to describe possible sexual dysfunctions after TBI. Additional material was also included to qualify the information drawn from the above format. A number of possible conclusions were drawn, indicating that the causes and effects of sexual functioning after TBI are very confusing and that the literature does not clarify this confusion. One cannot accurately differentiate between primary and secondary sexual problems and, therefore, cannot evaluate the contribution of each problem to the presented sexual dysfunction.     

American College of Preventive Medicine Practice Policy Statement: perimenopausal and postmenopausal hormone replacement therapy

Based on a review of current literature and recommendations, the American College of Preventive Medicine presents a practice policy statement on perimenopausal hormone replacement therapy.     

Bronchoscopic findings in post-obstructive pulmonary oedema

Purpose

To present the first photographed bronchoscopic findings associated with negative pressure pulmonary oedema (NPPE).

Clinical features

A previously healthy patient underwent anterior C₃–C₄ disc removal and arthrodesis. Following tracheal extubation he developed acute respiratory distress manifested as stridor, tachypnoea, restlessness, and desaturation. Once the trachea was reintubated, he displayed the classic findings of pulmonary oedema. Bronchoscopy was performed to confirm tracheal tube position and to rule out tracheal injury secondary to surgical manipulation. Diffuse punctate haemorrhages were noted throughout the visualised tracheobronchial tree.

Conclusion

We believe that these haemorrhages represent disruption of the bronchial vasculature and may contribute to the clinical presentation of NPPE.     

Molecular diagnosis of exocrine pancreatic cancer using a percutaneous technique

Background: The K-ras oncogene is activated by point mutations at codon 12 in most patients with exocrine pancreatic cancer. Mutant-enriched polymerase chain reaction (PCR) amplification can enhance the detection of mutated K-ras. This technique was applied to patients undergoing percutaneous fine-needle aspiration (FNA) biopsy of suspect pancreatic lesions. Methods: Twenty-five patients underwent percutaneous FNA of the pancreas for cytologic and molecular analysis. After preparing cytologic smears, the 22-gauge needle and syringe used for FNA were rinsed in RPMI-1640. The specimen was centrifuged, and DNA was extracted from the supernatant and subjected to mutant-enriched PCR using appropriate mismatched primers that introduce a BstNI restriction endonuclease cleavage site at codon 12 of wild-type, but not mutant, K-ras. After digestion with BstNI, the DNA was reamplified. To increase assay sensitivity, the final five PCR cycles were completed incorporating 5 μCi of (α-32P)dCTP. The DNA was then redigested and subjected to gel electrophoresis and autoradiography. Results: The median amount of DNA retrieved per specimen was 3.33 μg. Mutant K-ras was detected as a band of 143 bps; residual wild-type DNA was seen as a 114-bp fragment. Twenty-one of 25 specimens demonstrated mutated K-ras DNA. Two patients with nondiagnostic cytology results had mutated K-ras DNA; adenocarcinoma of pancreatic origin was confirmed in both cases after pancreatectomy. Conclusion: The molecular diagnosis of pancreatic cancer through identification of mutations in K-ras can be readily performed on specimens obtained by percutaneous FNA. As aggressive multimodality management of this disease becomes more common, pretreatment analysis of molecular determinants may have greater clinical significance. Presented at the 48th Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Neonatal herpesvirus sepsis following internal monitoring

The use of internal monitoring, in which an electrode is attached to the fetal scalp, may be associated with serious complications. The authors present a case of fetal neonatal sepsis due to herpesvirus arising at the electrode site.     

Treatment of diffuse metastatic cancer pain by instillation of alcohol into the sella turcica.

The technique of "chemical hypophysectomy" was modified for the management of pain due to metastatic cancer. Using stereotaxic control, a needle is introduced via the nose into the sella turcica. Absolute alcohol is then injected into the pituitary. Of 13 patients who had severe uncontrollable pain, 11 obtained marked symptomatic relief. The longest follow-up period to date is seven months, with results persisting. Sequelae are those associated with destruction of the pituitary gland, the most significant being diabetes insipidus. Several cerebrospinal fluid leaks prompted us routinely to instill alpha-ethyl cyanoacrylate to seal the sella floor. Three patients had slight extraocular nerve palsies. There was no death related to the procedure.     

Specificity in the Development of Vertical Connections in Cat Striate Cortex

The main efferent axons of pyramidal cells in layer 2/3 in the adult cat striate cortex make collateral connections specifically within layer 2/3 and layer 5 and avoid the intervening layer 4. Intracellular dye injections in vitro were used to determine how, during early postnatal development, this precise pattern of laminar connections was achieved. These investigations revealed that the pattern of collateral outgrowth was specific from the very earliest time that axons began sprouting collaterals. During the first postnatal week, sprouts were seen exclusively within layers 2/3 and 5; no evidence for a transient connection to layer 4 was observed. Furthermore, collaterals emerged simultaneously within layers 2/3 and 5, despite the large difference in the postmigratory ages of the two layers. By the end of the second postnatal week, the adult number of collaterals was achieved. Further elaboration of the local arbors occurred by repeated branching of already existing collaterals, rather than by addition of new collaterals to the main axon. These results demonstrate that the formation of local connections between cortical layers is highly specific, in contrast to the development of clustered horizontal connections by these same cells within layers 2/3 and 5, which involves extensive remodelling of local connections.     

Epidemiology of tetanus in S?o Paulo State (Brazil)]

Tetanus is a reportable disease in the State of S?o Paulo since 1978. The data from this source show a trend toward a decrease in the incidence of tetanus, although it is still higher than in the developed countries. There is a constantly high mortality rate. We have studied 133 cases of non-neonatal tetanus that had been reported to the Epidemiology Surveillance Center of the State of S?o Paulo in 1989. The data we analysed were obtained from the epidemiological report form routinely used during the investigation and confirmation of the cases. The incidence was 0.41 per 100.000 population and the mortality rate was 44.36%. It was possible to identify some groups under a higher risk like old-aged, those living in the western and north-western regions of the State and those classified occupationally as "domestic activities", "rural workers" and "pensioners". We propose that these groups deserve special attention, together with pregnant women and children. In 18.3% of the cases the incubation period could not be determined. The peak incidence occurred in May. We also compared the mortality rate in the group of patients in the Hospital das Clínicas da FMUSP (the only hospital in the State of S?o Paulo with an Intensive Unit Care designed exclusively to the treatment of the patients with tetanus) and the group of patients that were admitted to other hospitals. The mortality rate in the HC-FMUSP was 34.5% and in the other hospitals was 49.5%, but this was not statistically significant. The role of the medical facilities in the prognosis of the patient with tetanus specially the importance of considering at the same time the severity of the disease and the characteristics of the therapy deserve further study in order to contribute to the development of the medical assistance to the patients with tetanus.