Geriatric Treatment Center: a contemporary model for collaboration between psychiatry and neurology

The diagnosis and treatment of individuals with problems involving both psychiatry and neurology have become more sophisticated in recent years, but these advances may be difficult to implement in the modern health care environment. For 16 years, an inpatient Geriatric Treatment Center within a state mental hospital has been used to diagnose and treat older persons with complex neuropsychiatric disorders. Eight illustrative cases are presented of patients with major behavioral dysfunction that could not be managed effectively in other health care facilities. After neuropsychiatric evaluation and behavioral neurology consultation, all had neurologic diagnoses established as the cause of their presentation. Seven improved with appropriate treatment, of whom one could return to independent living, and the eighth died and had an autopsy diagnosis of his disease at a nearby academic medical center. This series highlights the value of collaboration between psychiatry and neurology for evaluation and treatment of older patients with neuropsychiatric problems not easily accommodated by many existing health care settings.     

Metabolic effects of growth hormone treatment: an early predictor of growth response?

Fourteen children receiving one year of recombinant human growth hormone (rhGH) treatment underwent measurement of serial changes in body composition (measured by skinfold thickness, bioelectrical impedance, and H2(18)O dilution), resting energy expenditure (REE, estimated by ventilated hood indirect calorimetry), and total free living daily energy expenditure (TEE, measured by the doubly labelled water technique). Mean height velocity increased from 4.9 to 8.6 cm/year after six months of treatment. Fat free mass (FFM) increased more during the first six weeks (24.4 g/day) than from six to 26 weeks of treatment (6.8 g/day); fat mass decreased by 7.2 g/day and 1.1 g/day respectively. The six week increase in REE (kJ/day) was maintained after six months of treatment, though expressed per kilogram FFM (kJ/kgFFM/day), returned to pretreatment values by three months. Height velocity increases at six months correlated with six week changes in fat mass measured by skinfold thickness and REE, though use of this relationship to predict growth response in individuals is limited by the wide 95% prediction intervals. No significant changes in growth, body composition, or energy expenditure were observed between six and 12 months of treatment, in either patients who had initially responded well to treatment or those who were poor initial responders to treatment and who had their dose of rhGH doubled after six months.     

Neonatal stroke: Clinical characteristics and cerebral blood flow velocity measurements

The clinical courses of 8 term infants with focal cerebral infarction or neonatal stroke were studied to determine whether such infants can be identified by current markers of perinatal distress, and whether changes in cerebral blood flow velocity (CBFV) occur during the acute phase of the disease. CBFV was measured from the middle cerebral artery (MCA) and anterior cerebral artery (ACA) utilizing duplex Doppler. Seven of the 8 patients required no resuscitation in the delivery room; 1 infant required brief bag and mask ventilation. No infant had evidence of severe fetal acidemia (i.e., cord pH <7). All 8 infants were initially admitted to the newborn nursery. Infants were identified on the basis of abnormal clinical findings observed during the first 48 hours: seizures (n = 6) and hypotonia and apnea (n = 2). Serum electrolytes, calcium, magnesium, and glucose levels were normal, and the sepsis evaluation including a spinal tap was sterile in all patients. Neuroimaging revealed nonhemorrhagic left focal MCA infarction (n = 6) and right focal MCA infarction (n = 2). Duplex Doppler demonstrated transient ipsilateral decreases in CBFV as compared to the contralateral unaffected side at clinical presentation in 4 infants. In 2 of these infants the decrease in CBFV involved both the MCA and ACA, and in 2 infants, only the MCA vessels. These side-to-side differences were not present at subsequent CBFV measurements. The data indicate that infants who develop neonatal stroke cannot be distinguished from infants who do not develop the lesion by current markers of perinatal distress. Because neonatal stroke frequently occurs as an unanticipated event, prevention may not be possible.     

Effect of patient behavior and personality on treatment planning.

Several models are described that show the interrelationship between the patient and his behavior/personality, the dentist, and the proposed plan of treatment for each patient. The patient assessment model is introduced, which asks neither the patient nor dentist to change, but through identification of personality characteristics of the patient, modifies the plan of treatment to fit the individual's need. To accomplish the aspect of personality assessment, the locus of control is employed. This instrument distinguishes between two distinct types of individuals, "internal" and "external." Through this classification of patients, the dentist can more clearly define the necessary treatment plan that fits the needs and wants of dissimilar patients.     

Comparable patterns of muscle facilitation evoked by individual corticomotoneuronal (CM) cells and by single intracortical microstimuli in primates: evidence for functional groups of CM cells

We compared the averaged responses of forelimb muscles to action potentials of single motor cortex cells and to single intracortical microstimuli (S-ICMS). Activity of precentral neurons and 12 identified forelimb muscles (6 flexors and 6 extensors of wrist and fingers) was recorded in macaques while they performed alternating ramp-and-hold wrist movements. Action potentials of cells that covaried reliably with wrist flexion or extension were used to compile spike-triggered averages (spike-TAs) of rectified electromyographic (EMG) activity of six synergistically coactivated muscles. Cells whose spikes were followed by a clear postspike facilitation (PSF) of rectified muscle activity were designated corticomotoneuronal (CM) cells. CM cells typically facilitated a subset of the coactivated muscles called the cell's target muscles. The relative strength of the PSF in different target muscles ranged from clear increases above base-line fluctuations to weak but significant effects. For each CM cell we characterized the "PSF profile" of facilitation across different muscles, defined as the relative strength of PSF in each of the coactivated agonist muscles. After identifying the CM cell's target muscles, we delivered S-ICMS through the microelectrode at the same site. Biphasic stimuli were delivered during the same wrist movements in which the recorded CM cell had been active. Stimulus intensities were too weak (typically 5-10 microA) and their repetition rate too slow (5-15 Hz) to evoke muscle excitation evident in the raw EMG record. However, stimulus-triggered averages (stimulus-TAs) of the rectified EMGs of coactivated muscles revealed consistent patterns of poststimulus facilitation (PStimF). In most cases the muscles facilitated by the CM cell in spike-TAs (n = 60) were also facilitated by S-ICMS in stimulus-TAs. At sites of CM cells the threshold stimulus intensities for evoking a statistically significant effect were between 0.5 and 2 microA. S-ICMS of 5 microA evoked PStimF that was, on the average, six times stronger than the PSF of the CM cell. The height of the facilitation peak relative to base-line fluctuations was 5-60 times greater for the stimuli than the spikes of the CM cell. The average onset latency of PStimF (8.0 +/- 1.2 ms) was 1.3 ms longer than the mean latency of PSF (6.7 +/- 1.4 ms). At two-thirds of the cortical sites where both spike- and stimulus-TAs were computed (n = 30), the PStimF profile exactly matched the PSF profile.(ABSTRACT TRUNCATED AT 400 WORDS)     

Misleading high tobramycin plasma concentrations can be caused by skin contamination of fingerprick blood following inhalation of nebulized tobramycin (TOBI): a short report

We observed unexpected high plasma concentrations of tobramycin (48.5 and 28.1 mg/L) in fingerprick blood samples after the nebulization of tobramycin solution for inhalation (tobramycin 300 mg/5 mL, TOBI by 2 young children aged 3 years. To investigate whether dermal contamination could be the source of error, 3 adult volunteers were present during another nebulization by a third child (age 2 years). The volunteers had exposure to tobramycin by handling the nebulizer or the nebule and also by inhalation from holding the child and being in close proximity while TOBI was being administered. Five blood samples by fingerprick and 2 by venipuncture were collected and assayed for tobramycin concentration. On each occasion the site was swabbed with alcohol wipes to mimic standard patient sampling methods. One site was resampled after cleaning of hands with 2% chlorhexidine gluconate and water. Tobramycin concentrations from venipuncture 1-2 hours after nebulization were all <0.2 mg/L except for 1 result of 1.2 mg/L. The tobramycin concentrations from fingerpricks before hand washing varied between 6.8 and 172 mg/L, and after hand washing between 0.3 and 17.6 mg/L. Contamination of fingers with tobramycin is likely to have caused the error in the 2 initial cases and did cause misleadingly elevated levels in the adult volunteers. We caution that therapeutic drug monitoring of nebulized tobramycin should not be done by fingerprick sampling, and care should be taken to avoid contamination of the venipuncture site.     

Hierarchy of nutritional knowledge that relates to the consumption of a functional food

OBJECTIVE: We assessed how consumption of a functional food relates to different combinations of nutritional knowledge. METHODS: American and Canadian subjects were asked by mail survey about their level of knowledge about soy and were assigned to one of four groups based on whether they had 1) no knowledge of soy, 2) attribute-related knowledge of soy, 3) consequence-related knowledge of consuming soy, or 4) both types of knowledge. Content analysis and analysis of variance were performed. RESULTS: The level of nutritional knowledge about soy did not necessarily influence how much people liked soy but was related to how much people consumed soy. In particular, consumers who were able to link attribute-related knowledge about soy to consequence-related knowledge about consuming soy were much more likely to consume soy than were those who only had one type of knowledge (average P < 0.007). CONCLUSIONS: Nutritional knowledge most likely correlates with consumption when people have attribute-related knowledge of the food and consequence-related knowledge of how it will benefit them. It is not the amount but the type of knowledge that matters. Educational strategies based only on attribute-related knowledge of functional foods and healthy products ("passing the nutrition quiz") may not effectively encourage the actual consumption of the food. Health care professionals and dietitians must link food attributes with personal health consequences when communicating to their patients.