Direct comparison of projections from the central amygdaloid region and nucleus accumbens shell

Certain neurochemical and connectional characteristics common to extended amygdala and the nucleus accumbens shell suggest that the two represent a single functional-anatomical continuum. If this is so, it follows that the outputs of the two structures should be substantially similar. To address this, projections from the caudomedial shell and central nucleus of the amygdala, a key extended amygdala structure, were demonstrated in Sprague-Dawley rats with different anterograde axonal tracers processed separately to exhibit distinguishable brown and blue-black precipitates. The caudomedial shell projection is strong in the ventral pallidum and along the medial forebrain bundle through the lateral preopticohypothalamic continuum into the ventral tegmental area, distal to which it thins abruptly. The central nucleus projects strongly to the bed nucleus of the stria terminalis and the sublenticular extended amygdala, but substantially to the lateral hypothalamus only at levels behind the rostral part of the entopeduncular nucleus. Innervation of the ventral tegmental area by the central amygdala is minimal, but the lateral one-third of the substantia nigra, pars compacta and an adjacent lateral part of the retrorubral field receive substantial central amygdala input. Central amygdaloid projections are robust in caudal brainstem sites, such as the reticular formation, parabrachial nucleus, nucleus of the solitary tract and dorsal vagal complex, all of which receive little input from the accumbens. The substantial differences in the output systems of the caudomedial shell of accumbens and central amygdala suggest that the two represent distinct functional-anatomical systems.     

Children with Autism Experience Problems with Both Objects and People

Kanner (1943), in his classic account, described autism as a specific impairment in interpersonal relations which leaves the child's uses of objects relatively unaffected. This combination of the difficulties in relating to people and the supposedly excellent relations to objects figures centrally within many of the current theories of autism, which have had relatively little to say on the question of object use. This paper draws attention to evidence of widespread impairments in relating to objects, not only in interpersonal aspects of object use but also in early sensorimotor exploration and the functional and conventional uses of objects. In stressing these problems with objects, our purpose is not to downplay the social dimension of autism, but rather to highlight the reciprocal nature of the interactions between the child, other people, and objects. Given the evidence that other people play an important role in introducing objects to children, we propose that an impairment in interpersonal relations should itself lead us to expect corresponding disruption in the autistic child's use of objects. Conversely, an unusual use of objects is likely to manifest itself in disturbances in relating to other people, given the importance of a shared understanding and use of objects in facilitating interaction.     

Rett syndrome: randomized controlled trial of L-carnitine

Rett syndrome is a severe neurodevelopmental disorder of unknown etiology, occurring almost exclusively in female patients. The etiology and functional significance of plasma carnitine deficiency seen in some patients with Rett syndrome is unknown. To investigate whether L-carnitine might be of benefit in Rett syndrome, a randomized, placebo-controlled, double-blind crossover trial of L-carnitine has been completed in 35 subjects. Eight-week treatment phases were completed for both a placebo and L-carnitine. Outcome was measured by parents/caregivers and at medical follow-up using three established tools: the Rett Syndrome Motor Behavioral Assessment, the Hand Apraxia Scale, and the Patient Well-Being Index. Analysis comparing change between baseline and week 8 of treatment for L-carnitine and the placebo showed that both parents/caregivers and medical follow-up detected improvements in the subjects' well-being. In addition, medical review showed an improvement on the Hand Apraxia Scale for a higher proportion of girls on L-carnitine. Identification of predictors of clinical improvement has been limited by the power of the study. These findings suggest that L-carnitine is of benefit in some patients with Rett syndrome. While L-carnitine did not lead to major functional changes in ability, the type of changes reported could still have a substantial impact on the girls and their families. Information is still needed, however, to determine if only subgroups of girls with the disorder are responsive to L-carnitine and the appropriate duration of therapy.     

The clinical usefulness of the renal allograft biopsy in the cyclosporine era: a prospective study

BACKGROUND: The renal allograft biopsy is generally accepted as the gold standard for clarifying the cause of renal dysfunction. However, the clinical usefulness of this procedure has rarely been studied prospectively, nor have most studies included follow-up of patients to delineate the influence of the biopsy on clinical outcome. In this study, we evaluated prospectively the clinical usefulness of the allograft biopsy in renal transplant recipients receiving cyclosporine (CyA). METHODS: During a 21-month period, 82 biopsies were performed. In 54 instances (47 patients), we outlined a presumed diagnosis and tentative treatment plan before the procedure. After the biopsy, a definitive diagnosis was made and an appropriate patient management approach was instituted. We analyzed the incidence of change in patient management that resulted from histological findings. All patients were followed to monitor their response to treatment and allograft survival. In cases of biopsy-proven acute cellular rejection (ACR) or cyclosporine (CyA) toxicity, clinical and laboratory data from the day of the biopsy were reviewed to determine their diagnostic value. RESULTS: One biopsy specimen was inadequate for definitive interpretation. The biopsy findings resulted in a change in patient management in 22 (41.5%) of the remaining 53 cases (change group). The incidence of altered patient management was 38.7% in biopsy specimens taken in the first month, 55.6% between 1 and 12 months, and 38.5% after 1 year posttransplantation. A change in management was required in 2 of 2 patients with chronic allograft dysfunction, in 44.4% of the 45 patients with acute allograft dysfunction, and in none of the patients with delayed graft function (n=6). Within the first week of treatment 19 of 22 (86.4%) in the change group and 25 of 31 (80.6%) in the no change group had a positive response to therapy. The 1-year allograft survival rate was also similar between the two groups. None of the clinical and laboratory data was useful in distinguishing ACR from CyA toxicity. CONCLUSIONS: Renal allograft biopsy findings alter patient management recommendations in approximately 40% of patients in whom a presumptive diagnosis had been made on the basis of clinical and laboratory findings. Patients who had a change in patient management because of biopsy findings demonstrated a response to therapy and allograft survival similar to those of patients who had no alteration in management plan after the biopsy.     

Staphylococcus lugdunensis pulmonary valve endocarditis in a patient on chronic hemodialysis

We describe a case of Staphylococcus lugdunensis pulmonary valve endocarditis in a 65-year-old woman on chronic hemodialysis and provide a review of previously reported cases. The patient presented with fever and altered mental status, but had no other localizing symptoms or signs; coagulase-negative staphylococcus (subsequently identified as S. lugdunensis) was isolated from two sets of blood cultures. Transthoracic and transesophageal echocardiograms showed a large (2.3 x 3.1 cm) vegetation on the pulmonary valve with moderate valvular insufficiency. The patient was treated with 6 weeks of antibiotic therapy and is stable 4 months following the completion of therapy; no surgical intervention was performed. Of the 28 previously reported cases of S. lugdunensis endocarditis, only 1 had previously survived with medical therapy alone. This is the 3rd case report of S. lugdunensis endocarditis in a patient on hemodialysis; the presumed portal of entry in this and previously reported cases was the vascular access device. Endocarditis due to this organism is characterized by a high mortality, rapid tissue destruction, and a predilection for native valves. Because the clinical outcome is much more favorable with valvular replacement, speciation of the organism assumes great importance in defining the therapeutic approach. Copyright Copyright 1999 S. Karger AG, Basel     

Action research: a useful method of promoting change in primary care?

BACKGROUND: Action research has been used successfully to promote change in disciplines other than medicine, but there are few examples of its use in primary care. OBJECTIVE: We aimed to discuss the benefits and difficulties of using action research in primary care using the example of child health surveillance provision in general practice. METHODS: Twenty-eight general practices were randomly allocated into two groups. Action research was used to promote change in 14 practices by facilitating practice meetings and by providing written feedback. The other 14 practices received written feedback alone. The two groups of practices were compared using the following: (i) semi-structured interviews with one health visitor and GP from each practice; (ii) observation of baby clinics; (iii) questionnaires to parents; and (iv) return rates of child health surveillance reviews from the personal child health record. RESULTS: All 14 practices in the action research arm of the study met as individual practice teams and decided to make changes to their provision of child health surveillance. Ten practices audited their child health surveillance as a result. More health visitors in the action research practices than in the comparison practices reported changes to child health surveillance, audit, communication and use of the personal child health record. The majority of health visitors and GPs thought involvement in the action research process was beneficial. However, we were unable to show a statistically significant difference between the two groups of practices in baby clinic provision, parent satisfaction or the return rate of child health surveillance reviews. CONCLUSION: Our study suggests that action research is a successful method of promoting change in primary care. However, measuring the impact of change is difficult.     

Individuals with low back pain: how do they view physical activity?

BACKGROUND: Recent guidelines for those with acute low back pain have advocated early resumption of normal activity and increased physical activity. Little is known about the relationship between low back pain and physical activity, and on the impact of that relationship on the promotion of increased levels of physical activity within a general practice population. OBJECTIVES: We aimed to explore associations between factors that influence changes in physical activity and the way individuals perceive and behave with their low back pain, and the impact of those perceptions and behaviour on physical activity. METHODS: Twenty-seven informants were chosen using a purposive sample from a larger group of individuals who, because of their low back trouble, had been referred by their GPs to a community-based, single-blind, randomized controlled trial (RCT) at the University of York, which is evaluating the effectiveness and cost-effectiveness of a progressive exercise programme. Fifty-four interviews were conducted with this subgroup of the RCT; four informants were interviewed once, 19 twice and four of them three times. Interviews were transcribed and analysed using manual and computer-aided approaches. RESULTS: Physical activity was perceived as (i) activities of daily living, (ii) activities causing breathlessness that they went out of the way to do and (iii) more competitive-type activity. The avoidance of physical activity and fear of pain returning were the two main factors directly associated with informants' backs and changes in physical activity. These two factors hindered increases in physical activity, even though the majority of informants believed strongly that being physically active helped ease their low back pain. CONCLUSIONS: When advocating that individuals with acute low back pain return to or increase physical activity, it is important that clinicians identify avoidance of physical activity and/or fear of pain at the earliest stage in order to tailor advice and reassurance appropriately. If avoidance of activity and fear of pain is identified and clinicians want to encourage patients to take up and sustain increased physical activity, they should explore issues of fear of pain, and avoidance of and confidence to do physical activities, in addition to other factors influencing physical activity.