Prevalence and prognostic significance of psychiatric disorders in patients evaluated for recurrent unexplained syncope

We aimed to assess the psychiatric profile and prognostic value of psychiatric disorders (PDs) in patients presenting with unexplained syncope. Forty patients with recurrent unexplained syncope referred for head-up tilt testing were compared with age- and sex-matched patients free of known chronic PDs referred for arrhythmia. All patients underwent a semistandardized psychiatry questionnaire (Mini-International Neuropsychiatric Interview) to assess their profile. Additional stress coping was performed to study adaptational processes to stressful situations. After tilt testing and psychiatric evaluation, a drug-free follow-up was performed in patients with syncope. Of the 80 patients who referred to the psychiatric interview, 40 had evidence of at least 1 psychiatric disorder. They were 26 patients (65%) in the syncope group and 14 patients (35%) in the control group (p = 0.01). Detailed analysis revealed a more frequent subprofile of anxiety and panic disorders in patients with syncope than in controls (30% vs 12% and 20% vs 10%, respectively), whereas the subprofile of depression was similar in both groups. Moreover, those with syncope were more likely to have a high anxiety index (25 +/- 5 vs 22 +/- 4, p = 0.004), and were more prone to avoidance-oriented coping strategies when experiencing undesirable life events than controls. Considering syncope patients, no difference could be found between the 25 with a positive tilt test and the 15 with a negative tilt test with respect to the number of syncopal episodes and psychiatric profile. After a 3-year drug-free follow-up, 15 patients (37.5%) had at least 1 recurrent syncope. The recurrence rate was similar in patients with positive and negative head-up tilt test results (9 of 25 vs 6 of 15, respectively). In contrast, the syncopal recurrence rate was higher in patients who fulfilled criteria for affective disorders (13 of 26 vs 2 of 14, 95% confidence interval 1.09 to 2.55, relative risk 1.7, p = 0.04). Thus, patients with recurrent unexplained syncope are more anxious and are more prone to panic disorders and avoidance-oriented coping strategies than control patients with arrhythmia. The presence of a psychiatric disorder is associated with an increased risk of recurrence. The outcome of such patients may be improved with recognition and treatment of PDs.     

Fetal alcohol syndrome prevention: annual and cumulative cost savings

Fetal alcohol syndrome (FAS) is a common developmental disability. FAS is thought to be 100% preventable. While this is a theoretical truth, a prevention rate of 100% appears unlikely in the near future. However, several prevention strategies are available. In this paper, we examine the potential cost savings from prevention of one case of FAS each year in the state of North Dakota.

We utilized the North Dakota Health Claims Database to examine annual cost of health care for children birth through 21 years of age with FAS and controls.

The mean annual cost of health care for children birth through 21 years of age with FAS was US$2842 (n=45). This is US$2342 per capita more than the annual average cost of care for children in North Dakota who do not have FAS (US$500 per year).

Prevention of one case of FAS per year in North Dakota would result in a cost savings of US$128,810 in 10 years and US$491,820 after 20 years. After 10 years of prevention, the annual savings in health care costs alone for one case of FAS would be US$23,420.     

Complex encounters at the macrophage-mycobacterium interface: studies on the role of the mannose receptor and CD14 in experimental infection models with Mycobacterium avium

The initial interactions between mycobacterial cell wall components and receptor structures on the surface of macrophages may be critical in determining the outcome of infection. They may trigger the ingestion and digestion of microorganisms, but they may also promote the intracellular persistence and growth of mycobacteria. Using Mycobacterium avium as a model system, three approaches of different complexities were used to analyse some structural features and some functional consequences of M. avium interacting with the macrophage mannose receptor or CD14, a pattern recognition receptor. Binding specificities of a recombinant, truncated extracellular portion of the mannose receptor were assayed in a novel ELISA-formatted system using viable M. avium cells as ligands. Infection with M. avium strains differing in their virulence were performed in murine bone marrow-derived macrophages and in mice with a targeted deletion of the CD14 gene. These parallel and converging approaches not only help define the molecular basis for understanding early events in the pathogenesis of mycobacterial infections, but are also necessary to ultimately determine the relevance of in vitro findings in the context of actual manifestations of disease in vivo.     

Initial management of immune thrombocytopenic purpura in adults: a randomized controlled trial comparing intermittent anti-D with routine care

We conducted a randomized clinical trial in adults with a new diagnosis of ITP and a platelet count <30000/muL to test the hypothesis that initial intermittent treatment with anti-D may avoid or defer the need for splenectomy when compared to current routine care (glucocorticoid treatment, followed by splenectomy). Splenectomy was to be performed in the anti-D group if patients failed to respond to three consecutive anti-D treatments given within 10 days. The incidences of splenectomy were 14 of 37 (38%) in the routine care group and 14 of 33 (42%) in the anti-D group (absolute risk reduction = 4.6% in favor of the routine care group, 95% CI, -18.4 to 27.6%). However, splenectomy was performed prematurely, not according to the protocol, in 11 of 14 patients in the anti-D group. The median time to splenectomy was 36 days (range, 9-78) in the routine care group and 112 days (range, 19-558) in the anti-D group (P = 0.045 at 100 days after randomization, P = 0.840 at 1 year after randomization, using log-rank analysis). Patients in the anti-D group were treated with prednisone for fewer days (70 days) compared to the routine care group (112 days, P = 0.01). No major bleeding events occurred. In this study, initial treatment of patients with intermittent anti-D initially deferred splenectomy. Whether our aggressive regimen of anti-D could have prevented splenectomy if it had been adhered to in all patients remains uncertain. However, compliance with this anti-D regimen was not feasible for many patients and/or their physicians.     

Encountering the person in his environment--approaches to psychosocial management

INTRODUCTION: Is it necessary to understand your vis a vis or is it enough to meet, to get in touch? Awareness of the different perception of reality is important. INTERINDIVIDUELL: Defined as basic requirements for getting in touch, mutual modelling and interchange were "Knowing your own world", "Being curious about the world of the other", candour and tolerance. Time makes the essential framework. GROUPS/ORGANISATIONS: Are the interindividuell parameters also practicable for groups/organizations? DISCUSSION: In the psychosocial context the subjective perception of the world is cause and cure at the same time. The basic requirements enable people, by getting in touch, to reorganize themselves.     

Diagnosis,treatment and progress after frontal lobe injury

The comprehensive assessment of a frontal lobe injury is one of the most complex problems in diagnosis and treatment due to the variability of nature, extent and effect of various disorders of higher cerebral functions, i. e. impairment of the ability to act systematically, attention, motivation and emotionality. This brings about considerable differences in assessing and judging the effects of frontal lobe syndromes. Impairments of initiation, planning and carrying out of actions, of impulse control, attention, memory and self-perception often manifest in disorganised and dissocial behaviour which brings about serious effects in many fields of social adaptability. Deeper neurological insights in nature and effects of these deficiencies and improved diagnostical methods and concepts of intensive-care treatment as well as the improved understanding in the necessity of a longterm rehabilitation program have led to the development of specific strategies concerning the dealing with the patient, the counseling of the social environment, especially of the relatives, and the treatment of the patient's symptoms. In the course of acute and rehabilitative treatment the patient normally has to develop strategies of habituation and adaptation to his social environment, furthermore techniques of compensation as well as an improvement of personal resources including attention, memory and planning of actions. The ability of self-control ought to be improved by training of behavioural strategies leading to an increased independence. The success of treatment varies distinctly from individual to individual. As a rule, basic capabilities in the scope of higher brain functions as well as executive and behavioural abilities can be improved. However, a restitutio ad integrum of all dysfunctions is very rare.