Attention deficit disorders persisting in adulthood: A review

The diagnostic term “minimal brain dysfunction” (MBD) has in the past been applied in child psychiatry to encompass a number of behavioral and learning problems with which children may present. Clements¹ cited, in order of frequency, an extended array of symptoms subsumed under this syndrome: (1) hyperactivity; (2) perceptual motor impairment; (3) emotional lability; (4) incoordination; (5) short attention span; (6) impulsivity; (7) disorders of memory and cognition; (8) specific learning disabilities; (9) deficits of speech and hearing; and (10) equivocal neurological findings.The construct validity of MBD and its congeners (Hyperactivity, Hyperkinetic Syndrome) has, however, come under general disrepute. Controversy has arisen over imprecise definitions, etiological speculations, pharmacological manipulations, and the moral and political implications of applying the term indiscriminately. Yet interest in such a distinct entity remains unabated, as may be surmised by the establishment of the Attention Deficit Disorders (ADD) in the recently revised psychiatric nomenclature.²The course of an MBD-like syndrome past childhood and adolescence seems to be extremely variable, probably a reflection of its etiological heterogeneity. While some children may adapt satisfactorily to the demands of adulthood, the literature suggests that residua such as learning difficulties and antisocial behavior tendencies may linger. These symptoms may provide clues to suspect the persistence of ADD in adults who might otherwise carry other psychiatric diagnoses. Therapeutic modalities are discussed, cautious conclusions are drawn, and suggestions are made for elaboration of further research.     

Postoperative Size of the Right Ventricular Outflow Tract and Optimal Age in Complete Repair of Tetralogy of Fallot

One hundred forty-three patients underwent complete repair of tetralogy of Fallot with an overall mortality of 14.7%. The mortality rate correlated with the preoperative pulmonary artery to aorta (PA/Ao) diameter ratio but not with age. A retrospective study revealed that for success, the postoperative pulmonary annulus should be over 1.75 cm² per square meter of body surface area (BSA) in patients with a BSA of less than 0.6 m² at operation. The younger the patient, the lower was the ratio of right ventricular to aortic systolic pressure, even when the cross-sectional area index (CSAI) of the pulmonary annulus was the same. Even with application of an outflow patch, pulmonary regurgitation was negligible when the CSAI was less than 2.6 cm²/m². The pulmonary vascular response to increased blood flow was excellent in younger patients. Residual ventricular septal defect and recurrent pulmonary stenosis were unrelated to age.Thus, for symptomatic patients, even infants, we recommend that complete repair be attempted when the PA/Ao diameter ratio is over 0.3. For patients in whom this ratio is less than 0.3, operation should be undertaken when the average diameter index of the arterial pathway to the right upper lobe is above 4 mm/m². Should this index be less than 4 mm/m², a two-stage operation is recommended.     

Coronary Atherosclerosis in Valvular Heart Disease

To evaluate the usefulness of routine coronary arteriography in patients undergoing cardiac catheterization for the evaluation of valvular heart disease, we performed coronary arteriographic studies routinely in a series of 201 patients primarily catheterized for such evaluation. Coronary artery obstructive lesions in excess of 50% of the lumen were present in 45 of the 201 patients. In 18 of the 45 there was no history of chest pain. Three of the 18 had three vessels involved while 2 had two vessels involved. A total of 27 patients (13.4%) had luminal obstruction greater than 70%, and 9 of these had no pain. In 35 of the 201 patients, classic angina pectoris existed in the absence of radiographically significant disease.Severe coronary disease was found to coexist with hemodynamically severe valvular heart disease and was not predictable noninvasively.     

Combined haloperidol and lithium carbonate in treating manic patients

In view of the recent discussion concerning the safety of combined therapy with haloperidol and lithium carbonate,^1,2 we wish to present our experience with 28 patients who received this combination of drugs for the treatment of acute mania.     

Field potential and single unit analyses of the avian dorsal motor nucleus of the vagus and criteria for identifying vagal cardiac cells of origin

The compound action potential components and their associated fiber contingents were investigated in the pigeon vagus nerve with a view toward identifying the vagal cardioinhibitory fibers. In the cervical vagus, the compound action potential evoked by electrical stimulation included four major components that conducted at 17.0-30.0 (A-wave), 8.0-14.5 (B2-wave) and 0.8-2.0 (C-wave) m/sec. Cardiac slowing was not elicited until activation of the Bl-wave, and the bradycardic response was maximal when this component was maximized. Electron microscopic analysis of the cervical vagus revealed myelinated fibers 1.1-6.8 micron in diameter and unmyelinated fibers 0.3-1.4 micron in diameter. A contingent of myelinated fibers approximately 2-4 micron in diameter apparently generated the Bl-wave, while the prominent unmyelinated fiber contingent (37%) accounted for the C-wave. Analysis of various vagal branches indicated that approximatley 20% of the cervical vagal fibers exit the main trunk between cervical and mid-thoracic levels, but few of these are the larger myelinated fibers greater than 2 micron in diameter. The upper abdominal vagus consists largely of unmyelinated and small myelinated fibers, and consequently the vast majority of larger myelinated fibers found in the cervical vagus exit between mid-thoracic and upper abdominal levels, presumably in the cardiac branches. Direct examination of the cardiac branches confirmed this. Thus, it is concluded that the Bl-wave of the compound action potential is uniquely associated with cardiac slowing, that this component is generated by myelinated fibers ranging from 2 to 4 micron in diameter, and that almost all such fibers are destined for the cardiac branches of the vagus.