Measurement by observations of aggressive behaviour and activities in clinical situations

Clinical aggression (towards self or other persons or things) is often thought of as having a certain degree of disease specificity. Thus, suicidal ideation is often associated with major depression, self-mutilation with borderline personality disorder, hostility with mania, negativism with schizophrenia or dementia and violence with explosive—impulsive disorder. Attempts to measure suicidal behaviour have pointed at the dimension of depression. Attempts to measure self-mutilation have shown that this is a behaviour without association to depression or suicidal behaviour. It seems to be associated with borderline disorders as well as mental handicaps. Attempts to measure outward aggression in the clinical situation have identified an aggression factor very similar to that found in the general population by Buss (1971) . This includes passive versus active aggression, direct versus indirect aggression, and verbal versus physical aggression. Among the clinical rating scales the nine-items Social Dysfunction and Aggression Scale (SDAS-9) covers this construct. Furthermore, the SDAS-9 measures both the generalised (day-to-day) aggression and aggressive acts. The scale is administered by the psychiatrist in collaboration with the nursing staff. Among scales specifically designed to be administered by the nursing staff are the Overt Aggression Scale (OAS), the Staff Observation Aggression Scale (SOAS), and the Scale for Assessment of Agitated and Aggressive Behaviour (SAAB). These three scales differ in the aspects of aggression to be measured and in the extent to which risk factors are considered. Among psychopathological risk symptoms are delusions, hallucinations, and lack of insight. Among other risk factors are medication and activities of daily living in the ward (ADL). It is important to differentiate in the measurement between aggressive behaviour and risk factors. Thus, the SDAS-9 measures aggressive behaviour (generalised and attacks), the Brief Psychiatric Rating Scale (BPRS) or the Maudsley Assessment of Delusion Schedule (MADS) measure psychopathological risk factors (e.g. delusions and hallucinations), and the SOAS measures other risk factors (e.g. medication and ADL) .     

Hard Metal Disease and Tool Room Grinding

The clinical and radiological findings in 12 cases of hard metaldisease in tool room grinders are described. Five were whollyemployed in tool sharpening and 8 on a part-time basis. Autopsieswere performed on 4, biopsies and autopsies in 2 and biopsyin 1. Pulmonary function studies were carried out in 8.The industrialprocess is briefly outlined and the literature reviewed. Thetoxicology of the metals is discussed. An account of the autopsy findings and the histological appearanceof lung tissue obtained at autopsy and at biopsy will be thesubject of another paper. Requests for reprints should be addressed to: Dr A. O. Bech, Consultant Chest Physician, Coventry and Warwickshire Hospital, Stoney Stanton Road, Coventry.     

PRODUCTION OF NON-STIMULATORY IMMUNOGLOBULINS THAT INHIBIT TSH BINDING IN Graves'' DISEASE AFTER RADIOIODINE ADMINISTRATION

The effect of a single dose of ¹³¹I upon thyroid stimulating immunoglobulins has been studied in twenty-two patients with Graves' disease. The thyroid stimulating immunoglobulins were assessed by parallel measurements of thyrotrophin receptor binding inhibitory immunoglobulins (TBII) and of thyroid adenylate cyclase stimulating immunoglobulins (TACSI) in serum by radioreceptor assay and stimulation of adenylate cyclase respectively. Prior to ¹³¹I therapy TBII were present in fourteen and TACSI in sixteen patients; seventeen were positive in one of the assays and thirteen in both assays. After radioiodine the level of both TACSI and TBII increased in most patients, but in six patients ¹³¹I therapy appeared to lead to a dissociation between the TBII and TACSI. After 12 months, nine patients were still positive in both assays, and twenty-one in one of the assays. In total, five patients developed hypothyroidism within 1 year after radioiodine. The TBII levels were significantly higher both before and 3 months after therapy in these patients than in those who remained euthyroid. Two of the hypothyroid patients developed non-stimulatory TSH binding inhibitory antibodies. The present study thus confirms that radioiodine therapy is followed by an increase of TBII and TACSI in most patients with Graves' disease. The level of TBII can probably provide a marker for development of hypothyroidism following ¹³¹I therapy and might be involved in its pathogenesis.     

Blood flow changes in the duck during thermal panting

Carotid and sciatic blood flow have been measured in resting and panting Pekin ducks using electromagnetic flowmeters. Panting induced by high ambient temperature caused the carotid blood flow to increase from 9.6 to 26.0 ml min^-1, while the sciatic flow declined slightly from 41.6 to 38.1 ml min^-1. During panting breathing rate increased 10–20 times, but there were no significant changes in heart rate and mean arterial blood pressure. The carotid peripheral resistance was therefore greatly reduced, whereas sciatic resistance remained unchanged or increased slightly. The vascular beds perfused by the sciatic (legs) and carotid (upper respiratory tract) arteries are both important for heat dissipation. This study shows that when heat dissipation from the naked legs becomes inefficient due to high ambient temperature, blood flow in the sciatic tended to decline while conversely panting was associated with a large increase in carotid flow.     

THE ACUTE CHANGES IN THYROID STIMULATING IMMUNOGLOBULINS,THYROGLOBULIN AND THYROGLOBULIN ANTIBODIES FOLLOWING SUBTOTAL THYROIDECTOMY*

The acute changes in thyroid adenylate cyclase stimulating immunoglobulins (TACSI), TSH binding inhibiting immunoglobulins (TBII), thyroglobulin (Tg) and thyroglobulin antibodies (TgAb) in serum after subtotal thyroidectomy were studied in thirteen patients with Graves' disease (GD) and thirteen patients with non-toxic goitre (NG). Prior to operation eight patients with GD were TACSI positive (mean ± SEM: 135·18%) and within 8 h following surgery TACSI increased and became positive in all thirteen patients (mean 172 ± 20%). There was a parallel increase in Tg and a decline in TgAb. A secondary rise in TACSI was observed 3–4 days after operation followed by a gradual fall which was associated with an increase in TgAb reaching a maximum 10 days after surgery. TACSI were still detectable 1 month postoperatively, but had disappeared by 3 months. In four of nine patients with GD TBII were present prior to operation. Immediately after surgery TBII decreased significantly (P < 0·05) and two of the four patients who were TBII positive became permanently negative, while the other two patients remained positive. A transient increase of the mean TBII levels was observed 5 days after surgery. Two of thirteen patients with NG were TACSI positive before operation and no significant changes were observed after surgery. The mean levels were significantly lower than in GD. Tg was measurable in eleven patients and showed a lower increase than in GD following surgery. TgAb were present in two patients prior to operation but disappeared in one and in the other one the changes following surgery were similar to the changes in GD.     

INFLUENCE OF TREATMENT WITH RADIOIODINE AND PROPYLTHIORACIL ON THYROID STIMULATING IMMUNOGLOBULINS IN GRAVES' DISEASE

Thyroid stimulating immunoglobulins (TSAb) were measured in fifty-four patients with Graves' disease before treatment with either radioiodine (seventeen patients) or propylthiouracil (PTU) (thirty-seven patients), and followed during treatment. After radioiodine TSAb increased to levels exceeding pre-treatment values, and became detectable in three of six originally TSAb negative patients.
In most patients TSAb decreased during treatment with PTU, and became undetectable after a mean of 12 months in patients above 40 years, and after a mean of 6 months in patients below 40 years. In order to eliminate the presumed causative agent in Graves' disease, antithyroid treatment should be at least 18 months in patients above 40 years, and at least 12 months in patients below 40 years of age. In twenty-nine patients TSAb were measured at cessation of 2 years antithyroid drug therapy. Ten patients were TSAb positive and all except one relapsed. Five of nineteen TSAb negative patients relapsed. Although TSAb positivity predict relapse, it is not an ideal index of prognosis after antithyroid therapy.     

HUMAN THYROID ADENYLATE CYCLASE IN NON-TOXIC GOITRE: SENSITIVITY TO TSH, FLUORIDE AND THYROID STIMULATING IMMUNOGLOBULINS

Homogenates prepared from human thyroid tissue obtained at operation for non-toxic goitre were separated by differential centrifugation into 1000 g, 5000 g, 10,000 g and 37,000 g fractions. The fractions showed varying amounts of TSH (12.5 mu/ml) and fluoride (10 mmol/1) sensitive adenylate cyclase activity. The 5000 g pellet contained the highest amount of TSH-sensitive adenylate cyclase activity calculated per mg protein. Of other potential activators tested only fluoride, immunoglobulins from patients with Graves' disease and adrenaline (10?⁶ mol/l) caused significant stimulation in this fraction, which was selected for further studies. Maximal activation of adenylate cyclase was obtained with 75 mu TSH/ml incubate, half maximal stimulation with 2.9 mu TSH/ml and detectable stimulation was found with 0.0125 mu TSH/ml. Supramaximal concentrations (1.25 u/ml) gave a decreased response. Stimulation with TSH resulted in a linear production of cyclic AMP for 40–60 min dependent on the TSH concentration. 30 min pre-incubation of homogenate with TSH at 4°C did not influence the response after addition of ATP-buffer and subsequent incubation at 37°C, suggesting a very rapid equilibrium for binding of TSH to its receptor after addition of ATP-buffer to the system. In the 5000 g fraction stimulation of adenylate cyclase with TSH 12.5–75 mu/ml incubate exceeded that obtained with fluoride, and when combined in maximal concentrations an additive effect was observed after incubation for 40 and 60 min, but not after 10 and 20 min, and fluoride caused a linearization of the cAMP response to maximally stimulatory concentrations of TSH. Thus, fluoride appears to maintain the TSH stimulated adenylate cyclases in a maximally activated state. The 5000 g fraction was sensitive to stimulation with immunoglobulins (TSI) from ten of eleven randomly selected patients with untreated Graves' disease. TSI stimulated adenylate cyclase activity could exhibit a lag-phase of at least 20 min, and stimulation was most readily detected after 60 min incubation at 37°C. The TSI preparations from patients with Graves' disease exhibit varying degrees of lag-phase indicating that TSI is a heterologous class of immunoglobulins with activation kinetics distinctly different from those of TSH.