Chylous ascites after radical nephrectomy and inferior vena cava thrombectomy. Successful conservative management with somatostatin analogue

Postoperative chylous ascites is a rare complication of retroperitoneal surgery. The treatment of postoperative chylous ascites is primarily conservative, consisting of repeated paraceteses, medium chain triglyceride (MCT) diet, salt restriction, diuretics and bowel rest with total parenteral nutrition. Occasionally, chylous ascites may take a protracted course which may necessitate insertion of peritoneo-venous shunts or direct surgical lymphostasis. Recently, Somatostatin was shown to be highly effective in closure of refractory lymphatic fistulas. We present a case of refractory chylous ascites following radical nephrectomy with inferior vena caval thrombectomy that failed to respond to conventional conservative measures and resolved rapidly following the administration of Somatostatin.     

Concordance for cognitive impairment: a study of 50 community-dwelling elderly female-female twin pairs

The present study sought to determine concordance of cognitive impairment among elderly female twins. Cognitive testing was performed by telephone interview in a sample of 100 female-female twins older than 65 years. The participants were 32 monozygotic (MZ) and 18 dizygotic (DZ) female twin pairs, all between the ages of 65 and 86 years; their mean age was 70.2 +/- 4.6 years. All were recruited from the Institute of Psychiatry Volunteer Twin Register (IPVTR). We used the Telephone Interview for Cognitive Status (TICS) and analyzed the modified total score. Correlation's of age and zygosity were computed in relation to score on cognitive interview, and differences between MZ twin pairs (n = 32) and DZ pairs (n = 18) were analyzed using the general linear model procedure. Five subjects of the 64 MZ females (7.8%) and one DZ female (2.4%) were found to be cognitively impaired. In no case was the second twin affected. No differences in cognitive score were found between MZ and DZ twin pairs. In both groups a highly significant correlation was found between age and lower score: R(2) = -0.32, P =.009. We conclude that aging-related impairment in cognitive testing did not differ between MZ and DZ elderly female twins. Although the overall sample size was relatively small and error variance may have been introduced by imprecise measures of zygosity, the present findings are suggestive of gender differences in cognitive performance that need further evaluation.     

Characterizing the elderly homeless: a 10-year study in Israel

Since 1980s there is a noticeable change in the homeless population in Western countries. Some researchers titled the change as the "new" homeless that are distinctly different than the "skid row" population described in the past. Among the "new" homeless there are increasing numbers of elderly subjects. The elderly homeless are a fragile and vulnerable group that suffers from high rates of physical and mental problems as well as increased mortality. The aim of the present study was to characterize the "new" elderly homeless. Over a 10-year period each homeless 65 years of age and older was assessed by a psychiatrist. The project was undertaken in Tel-Aviv, Israel, and was feasible due to close co-operation between the Municipal Welfare Department and mental health consultants. The Structured Clinical Interview for DSM-IV (SCID) was the main diagnostic tool. Ninety-eight subjects of 2567 homeless persons located and contacted were elderly (3.8%). Mean age for the elderly sub-group was 71.7+/-5.3 years and the great majority were male 94/98 (95.9%). In 44/98 (44.9%), a formal DSM-IV axis I psychiatric disorder was diagnosed, most common being dementia (15/44) and schizophrenia (15/44). A significant minority of 13/44 (29.5%) were diagnosed and treated prior to becoming homeless. Physical co-morbidity was found in nearly 2/3 subjects. Following intensive case-management by social workers, 35/44 (79.5%) subjects were successfully placed in permanent housing. The main conclusion is that the "new" elderly homeless are typically males suffering from frequent psychiatric morbidity and physical co-morbidity. Intensive case-management succeeded in achieving return to permanent housing in the majority of subjects.     

Effect of low-carbohydrate, unlimited calorie diet on the treatment of childhood obesity: a prospective controlled study

Background: Childhood obesity has been recognized as the new epidemic in developed countries. Caloric restriction with physical activity is the main therapeutic treatment available for these children. We compared two different dietary protocols to assess treatment efficacy. Methods: Obese children from the Pediatric Endocrinology clinic were prospectively recruited for the study. Children and their parents were allowed to choose one of two dietary protocols: (1) carbohydrate restricted diet (<30 g/day), with unlimited calories, protein, and fat (High protein, Low CHO Diet), and (2) calorie restricted diet (Low Cal Diet). Anthropometric data were measured at baseline and at the 2 month follow up appointment. Results: Thirty-seven children completed the study of whom 27 chose High Protein, Low CHO Diet and 10 chose Low Cal diet. No differences in gender ratio, age, or BMI were observed at baseline. At 2 months, children in the High Protein, Low CHO Diet lost an average of 5.21 +/- 3.44 kg (p < 0.001) and decreased their BMI by 2.42 +/- 1.3 points (p < 0.001), compared to the children in the Low Cal Diet who gained an average of 2.36 +/- 2.54 kg and 1.00 point on the BMI value (p < 0.001). Conclusions: A high protein, low carbohydrate, unlimited calorie diet was superior to a restricted calorie protocol for weight loss in obese school age children; moreover, compliance was better.     

Attitudes Toward Sexuality Among Nursing Home Residents

There is a paucity of data regarding sexuality among nursing home residents. The aim of the present study was to evaluate sexual attitudes in a group of independent residents in a large urban nursing home. Ten items covering different aspects of sexual attitude were scored by two board certified psychiatrists following a semistructured interview. The study was undertaken at a large 1,200-bed nursing home providing services to both healthy independent elderly as well as geriatric patients. Subjects were 31 volunteers: 15 men and 16 women (mean age: 82.4 and 74.1 years, respectively), who consented to participate. Participants were cognitively intact and living independently at the nursing home. Exclusion criteria were: a) current major psychiatric morbidity, b) drug or alcohol abuse, c) Geriatric Depression Scale (short version) score 5, and d) Clinical Dementia Rating >0. A hierarchy of basic functions was constructed wherein each function was graded on a 5-point Likert-like scale reflecting its endorsed importance. The majority (23/31) felt that sexuality should be openly discussed with the elderly by health professionals. Twenty-one of 31 expressed willingness to receive medical consultation and treatment for sexual dysfunction as needed and 20/31 expressed a similar attitude if their partner so needed. The hierarchy of needs was rated by the participants (men and women, respectively) as follows: Mood (4.4; 4.3), Memory (4.2; 4.2), Sleep (3.8; 3.9), Sex (3.5; 2.8), and Appetite (2.8; 2.6). Sex is graded as moderately important among nursing home residents, more so in males. The majority of residents expressed positive attitudes towards open discussion of sexual matters and willingness to accept therapeutic interventions when needed.     

Screening for early cognitive impairment in multiple sclerosis patients using the clock drawing test

The clock drawing test (CDT) is a complex task assessing integrative functions, abstract thinking and visuospatial organization. In the present study we evaluated the CDT as a possible screening instrument for early cognitive impairment in multiple sclerosis (MS) patients. In total, 107 MS patients completed the CDT as well as a battery assessing five cognitive domains. There were 73 female and 34 male participants (mean age 45.4+/-11.6 years, range 19-69). The majority (76/107) were diagnosed with a relapsing-remitting disease course. Mean expanded disability status scale (EDSS) score was 4.3+/-2.4 (range 0-8). The CDT was scored on a 1-6 point scale with "1" being a perfect score and "6" reflecting severe disorganization. Mean CDT score was 2.6+/-1.4. In 53% of patients the CDT was normal while in 11.2% dementia was apparent. The CDT score did not correlate with the total EDSS. Significant correlations were obtained with the mental functional system score of the EDSS (r = 0.78; p = 0.0001), visual learning and recall, sustained attention and concentration. Our findings demonstrate the sensitivity of the CDT to several cognitive domains. The absence of correlation with total EDSS score coupled with significant correlation with the mental functional system suggests that the CDT may be useful for screening MS patients.     

Suicide in Israel: 1985-1997

OBJECTIVE: To examine trends in suicide rates in Israel over a 13-year period. METHOD: All cases of autopsy-confirmed suicide in Israel from 1985 to 1997 were retrospectively reviewed. RESULTS: An overall annual increase in suicide rates, with rates in men 3 times higher than those in women, was observed. Suicide rates were highest in the second and third decades of life. Unlike Western countries where gunshot wounds are the most common method of suicide for men and poisoning is most common for women, asphyxiation by hanging was the most common method used by men in Israel, followed by firearm wounds and jumping from heights. In women, however, jumping from heights was the most common method, followed by hanging and poisoning. CONCLUSION: Increasing rates of suicide may be associated with waves of immigration to Israel, increased substance abuse and depression and the political and social climate. Further study to examine the precipitating factors is warranted.     

Suicide amongst Alzheimer's disease patients: a 10-year survey

Suicide is a major public health problem with advancing age being one of the factors associated with increased risk. It has been suggested that most DSM axis-I disorders contribute to increased suicidal risk while dementia is one of the few exceptions. We conducted a 10-year retrospective analysis of all elderly patients suffering from dementia admitted to a large urban mental health center. Between 1991 and 2000 there were 1,551 admissions to our center who were 65 years or older. Of these, 341 were diagnosed (DSM-IV criteria) as suffering from dementia and 215/341 as suffering from Alzheimer's disease (AD). Sixteen AD patients (7.4% of all AD patients) were admitted immediately following a suicide attempt. The control group consisted of the next admission of an elderly AD patient matched for age and gender. The index group (suicidal patients) differed from controls in Clinical Dementia Rating scores (p = 0.017) and higher frequency of previous suicide attempts (p = 0.022). Lifetime psychopathology was not associated with higher rates of suicide attempts (p = 0.068). Physicians should be aware that suicide attempts are not rare in elderly AD patients. Higher level of daily functioning and previous suicide attempts are associated with increased suicidal risk.     

No weight gain among elderly schizophrenia patients after 1 year of risperidone treatment

OBJECTIVE: Weight gain has been reported in younger patients treated with most atypical neuroleptics. The goal of this study was to examine whether elderly schizophrenic patients gain weight while being treated with risperidone. METHOD: Data are from an international multicenter, open-label study of 180 elderly (69 men, 111 women), chronically ill, psychotic patients (meeting DSM-III-R criteria for schizophrenia or schizophreniform disorder; median age = 72 years [range, 54-89 years]), 97 of whom completed the 12-month study. At endpoint, the mean dose of risperidone was 3.7 mg/day. Patients were weighed at baseline and at endpoint. RESULTS: There was no significant weight gain in patients who completed the trial (N = 96) or in those who did not complete the entire trial (N = 31). CONCLUSION: The results suggest that risperidone treatment is not associated with weight gain among elderly persons with chronic psychosis.     

Progressive parkinsonism in a young experimental physicist following long-term exposure to methanol

A case is described of an experimental physicist who developed parkinsonism, apparently as delayed toxic effect of long exposure to vapors of methanol in the laboratory. Clinical and magnetic resonance imaging (MRI) supported the diagnosis, after exclusion of hereditary diseases and primary degenerative diseases. Screening for heavy metals in urine and plasma ceruloplasmin was negative. This case illustrates the neurotoxic delayed effect of long-term exposure to methanol with no episodes of acute intoxication. The setting of a research laboratory with prolonged exposure to mixed single crystals and inhalation of methanol vapors may exist in other academic and hi-tech environments, and pose the risk of similar delayed toxic influences.