Biomedical subjects
L A Neal
Publications and source records attributed to L A Neal.
Medical help-seeking by motor vehicle accident claimants.
The assessment of general psychiatric damages in personal injury cases is partly determined by evidence that the claimant has attempted to mitigate their losses by seeking medical help. However, there is no evidence that seeking medical help for a psychiatric injury is typical behaviour. The general practice consultation behaviour of 100 claimants with chronic physical and psychiatric injury with an onset at the time of a motor vehicle accident, was assessed over a 12-month period after the injury. GP consultations for physical and psychiatric symptoms were compared. At 12 months after the accident 53 (95% CI 42.7, 63.3) had consulted their GP with psychiatric symptoms and 94 (95% CI 88.8, 99.2) had consulted their GP with physical symptoms. Neither the sex, age or a pre-accident history of help-seeking for psychological symptoms was significantly predictive of post-accident help seeking for psychiatric injury. The results from this study provide information about the weight that should be given to medical help-seeking as a factor in assessing the value of claims for general psychiatric damages in personal injury cases.
Reliability of history and physical examination findings for assessing control of glycemia in dogs with diabetes mellitus: 53 cases (1995-1998).
OBJECTIVE: To evaluate the reliability of history and physical examination findings for assessing control of glycemia in insulin-treated diabetic dogs. DESIGN: Retrospective study. ANIMALS: 53 insulin-treated dogs with diabetes mellitus. PROCEDURE: Medical records of insulin-treated diabetic dogs from June 1995 to June 1998 were reviewed, and information on owner perception of their dog's response to insulin treatment, physical examination findings, body weight, insulin dosage, and concentrations of food-withheld (i.e., fasting) blood glucose (FBG), mean blood glucose (MBG) during an 8-hour period, blood glycosylated hemoglobin (GHb), and serum fructosamine was obtained. Owner's perception of their dog's response to insulin treatment, physical examination findings, and changes in body weight were used to classify control of glycemia as good or poor for each dog. The FBG, MBG/8 h, blood GHb, and serum fructosamine concentrations were compared between well-controlled and poorly controlled insulin-treated diabetic dogs. RESULTS: Presence or absence of polyuria, polydipsia, polyphagia, lethargy, and weakness were most helpful in classifying control of glycemia. Mean FBG and MBG/8 h concentrations, blood GHb concentrations, and serum fructosamine concentrations were significantly decreased in 25 well-controlled diabetic dogs, compared with 28 poorly controlled diabetic dogs. Most well-controlled diabetic dogs had concentrations of FBG between 100 and 300 mg/dl, MBG/8 h < or = 250 mg/dl, blood GHb < or = 7.5%, and serum fructosamine < or = 525 mumol/L, whereas most poorly controlled diabetic dogs had results that were greater than these values. CONCLUSIONS AND CLINICAL RELEVANCE: Reliance on history, physical examination findings, and changes in body weight are effective for initially assessing control of glycemia in insulin-treated diabetic dogs.
Effect of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus.
OBJECTIVE: To evaluate effects of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. DESIGN: Randomized controlled crossover trial. ANIMALS: 16 cats with naturally acquired diabetes mellitus. PROCEDURE: Cats were fed a diet high in insoluble fiber (HF) containing 12% cellulose (dry-matter basis) or a diet low in insoluble fiber (LF) for 24 weeks; they were fed the other diet for the subsequent 24 weeks. Caloric intake and insulin treatment were adjusted to maintain stable body weight and control of glycemia, respectively. Cats were allowed an adaptation period of 6 weeks after initiation of a diet, after which control of glycemia was evaluated at 6-week intervals for 18 weeks. Variables assessed included serum glucose concentration measured during the preprandial state, blood glycated hemoglobin concentration, serum glucose concentration measured at 2-hour intervals for 12 hours beginning at the time of the morning insulin injection, 12-hour mean serum glucose concentration, and mean fluctuation in serum glucose concentration from the 12-hour mean serum glucose concentration. RESULTS: Mean daily caloric intake, body weight, or daily insulin dosage did not differ significantly between cats when fed HF and LF diets. Mean preprandial serum glucose concentration, most post-prandial serum glucose concentrations, and the 12-hour mean serum glucose concentration were significantly lower when cats consumed the HF diet, compared with values when cats consumed the LF diet. CONCLUSIONS AND CLINICAL RELEVANCE: These results support feeding a commercially available diet containing approximately 12% insoluble fiber (dry-matter basis) to cats with naturally acquired diabetes mellitus.
Comparison of serum fructosamine and blood glycosylated hemoglobin concentrations for assessment of glycemic control in cats with diabetes mellitus.
OBJECTIVE: To correlate serum fructosamine concentrations with established measures of glycemic control and to compare serum fructosamine and blood glycosylated hemoglobin (GHb) concentrations as a means for assessing glycemic control in diabetic cats. DESIGN: Longitudinal cohort study. ANIMALS: 26 healthy cats, 5 cats with stress-induced hyperglycemia, 15 untreated diabetic cats, and 36 treated diabetic cats. PROCEDURE: Control of glycemia was classified and monitored and serum fructosamine and blood GHb concentrations were measured for 12 poorly controlled diabetic cats before and after improving glycemic control, 8 well-controlled treated diabetic cats before and after glycemic control deteriorated, and 5 cats with diabetes mellitus before and after onset of stress-induced hyperglycemia. RESULTS: Mean serum fructosamine and blood GHb concentrations were significantly higher in untreated diabetic cats, compared with healthy cats, and in 24 poorly controlled diabetic cats, compared with 12 well-controlled diabetic cats. Mean serum fructosamine and blood GHb concentrations decreased significantly in 12 poorly controlled diabetic cats after improving glycemic control and increased significantly in 8 well-controlled diabetic cats after glycemic control deteriorated. A significant stress-induced increase in mean blood glucose concentration was evident 12 hours after insulin administration, but not in 5 docile diabetic cats that became fractious. CLINICAL IMPLICATIONS: Serum fructosamine and blood GHb concentrations are clinically useful tools for monitoring control of glycemia in cats with diabetes mellitus.
Glycosylated hemoglobin concentrations in the blood of healthy dogs and dogs with naturally developing diabetes mellitus, pancreatic beta-cell neoplasia, hyperadrenocorticism, and anemia.
OBJECTIVE: To characterize glycosylated hemoglobin (GHb) concentrations in the blood of dogs with disorders that may affect serum glucose or blood GHb concentrations, and to determine whether changes in GHb concentration correlate with changes in control of diabetes in dogs. DESIGN: Prospective study. ANIMALS: 63 healthy dogs, 9 dogs with anemia, 24 dogs with untreated hyperadrenocorticism, 12 dogs with pancreatic beta-cell neoplasia, 23 dogs with newly diagnosed diabetes mellitus, and 77 diabetic dogs treated with insulin. PROCEDURE: Control of diabetes in dogs treated with insulin was classified as good or poor on the basis of history, physical examination findings, changes in body weight, and measurement of serum glucose concentrations Sequential evaluations of control were performed and GHb concentration in blood was measured, by means of affinity chromatography, for 5 untreated diabetic dogs before and after initiating insulin treatment, for 10 poorly controlled diabetic dogs before and after increasing insulin dosage, and for 5 diabetic dogs before and after pancreatic islet cell transplantation. RESULTS: Mean (+/-SD) GHb concentration was 3.3 +/- 0.8% in the blood of healthy dogs. Compared with results from healthy dogs, mean GHb concentration was significantly lower in the blood of dogs with anemia and pancreatic beta-cell neoplasia and significantly higher in the blood of untreated diabetic dogs. Mean GHb concentration was significantly higher in the blood of 46 poorly controlled diabetic dogs, compared with 31 well-controlled diabetic dogs (7.3 +/- 1.8 vs 5.7 +/- 1.7%, respectively). Mean GHb concentration in blood decreased significantly in 5 untreated diabetic dogs after treatment (8.7 +/- 1.9 vs 5.3 +/- 1.9%). Mean GHb concentration in blood also decreased significantly in 10 poorly controlled diabetic dogs after control was improved and in 5 diabetic dogs after they had received a pancreatic islet cell transplant. CLINICAL IMPLICATIONS: Measurement of GHb concentration in blood may assist in monitoring control of diabetes in dogs.
Diencephalic tumours presenting as behavioural problems in the workplace.
Two patients presented with histories of significant behavioural disturbance and deteriorated work performance. Subsequent investigations confirmed the presence of a craniopharyngioma and a prolactinoma. Occupational physicians should consider excluding organic pathology in employees with histories of an unexplained marked change in work performance and behaviour.
An open trial of moclobemide in the treatment of post-traumatic stress disorder.
Traditional monoamine oxidase inhibitors have shown efficacy in the treatment of post-traumatic stress disorder, but their use is limited by some serious drug and food interactions. Moclobemide, which is a reversible inhibitor of monoamine oxidase-A, is relatively free of these limitations and is therefore potentially useful in the treatment of post-traumatic stress disorder. Twenty patients who met Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM-III-R) criteria for post-traumatic stress disorder were entered into a 12-week open study with moclobemide. Assessments were completed every 4 weeks. Eleven participants no longer met DSM-III-R criteria for post-traumatic stress disorder by week 12. The severity of post-traumatic stress disorder reduced by 2.09 SD (95% confidence interval 1.49-2.69; p < 0.001) and functional impairment improved by 1.08 SD (95% confidence interval 0.46-1.69; p < 0.01). Adverse events were minimal. Controlled, double-blind studies should be considered to confirm these findings.
Development and validation of a computerized screening test for personality disorders in DSM-III-R.
The available self-report instruments designed to measure personality disorder (PD) are time-consuming to administer and/or score and can be impractical for routine clinical use. There is a need for a computerized method of personality assessment based on contemporary systems of classification. A computerized DSM-III-R-based questionnaire was developed and validated against the structured clinical interview for DSM-III-R Axis-II disorders on a sample of 60 subjects. The computerized test showed moderate validity as a diagnostic instrument (mean kappa coefficient = 0.47). With adjusted cut-off scores it was valid as a screening instrument (mean sensitivity = 0.87). Antisocial, borderline and avoidant PD scores were strongly correlated across measures and not subject to significant observer bias.
Factitious post traumatic stress disorder: a case report.
A 24-year-old man presented with a convincing history of Post Traumatic Stress Disorder (PTSD). He claimed to be the victim of a widely publicized 'human bomb' attack by the IRA in Northern Ireland when he was serving with the armed forces. Psychometric tests for PTSD confirmed his symptoms. A subsequent check of public and military records demonstrated that he was a serviceman at that time, but showed conclusively that he could not have been present at the terrorist incident.
Incorporating psychological debriefing techniques within a brief group psychotherapy programme for the treatment of post-traumatic stress disorder.
BACKGROUND: The Royal Air Force Wroughton Post-Traumatic Stress Disorder (PTSD) Rehabilitation Programme is described. It comprised a 12-day structured in-patient 'course' of group psychotherapy and day-case group follow-up sessions over a one-year period. Psychological debriefing was the main therapeutic technique employed. METHOD: This is a 'before and after' open outcome study. A comprehensive assessment protocol confirmed the presence and severity of PTSD and measured co-morbid psychopathological status, occupational and social function longitudinally. RESULTS: A highly significant global response to treatment is demonstrated in the 34 subjects included in the study, with 85.3% not fulfilling the DSM-III-R criteria for PTSD at one year after treatment. CONCLUSIONS: Further controlled studies assessing the value of psychological debriefing techniques in the treatment of established PTSD are required.
Persistent post-traumatic stress disorder. Former prisoners of war show symptoms.
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Convergent validity of measures of post-traumatic stress disorder in a mixed military and civilian population.
The authors evaluated the validity of the Post-Traumatic Stress Disorder (PTSD) subscale of the Minnesota Multiphasic Personality Inventory (MMPI), the Impact of Event Scale (IES) and the Symptom Check List 90 (SCL-90) as continuous and dichotomous measures of PTSD in a mixed military and civilian group of 70 subjects in the United Kingdom. The MMPI-PTSD and the IES are designed specifically as measures of PTSD and the Global Symptom Index of the SCL-90 is a general measure of neurosis. All measures produced significant positive correlations with scores from the Clinician Administered Post-Traumatic Stress Disorder Scale (CAPS-1) and with each other. The IES was the most useful dichotomous measure. The optimum cut-off score for the IES producing the highest Positive Predictive Value and the lowest Apparent Total Misclassification Error Rate has been determined.
Development and validation of the computerized clinician administered post-traumatic stress disorder scale-1-revised.
A computer administered version of the clinician administered post-traumatic stress disorder (PTSD) scale-1 was developed to assess PTSD in subjects presenting with psychological symptoms following exposure to a traumatic event. Both forms were administered to 40 subjects who met the Diagnostic and Statistical Manual, third edition, revised (DSM-III-R) criteria for exposure to a significantly traumatic stressor. Inter-observer reliability was demonstrated with a kappa statistic of 0.90. The computer version had a sensitivity of 0.95 and a specificity 0.95. A correlation of 0.95 was found between the two versions and the mean score difference was non-significant. The computer form demonstrated adequate internal reliability and test-retest reliability. Overall results suggest the computer version is a valid and reliable measure of PTSD.
The pitfalls of making a categorical diagnosis of post traumatic stress disorder in personal injury litigation.
Since it first became possible to diagnose Post Traumatic Stress Disorder (PTSD) categorically with the advent of DSM-III (American Psychiatric Association, 1980), its use in the American Courts to substantiate civil claims has burgeoned. This situation may be set to repeat itself in the UK. Mental health professionals need to be aware that there is a substantial body of evidence supporting the validity of the concept of a DSM diagnosis of PTSD. However, the reliability of such a diagnosis can be called into question. There are legal and ethical issues involved in assessing and interpreting the DSM criteria, some of which may lead the expert witness to make authoritative pronouncements that are outside his legitimate field of expertise. There is a danger that the legal profession will adopt the DSM as a 'gold standard' against which to judge expert testimony. The multiaxial classification of the DSM can be a useful framework for presenting a diagnosis of PTSD, but over-rigid adherence to the criteria at the expense of clinical judgement and experience should be avoided.
The importance of severity as a factor in post-traumatic stress disorder.
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Outcomes of lower extremity amputations.
In an effort to identify variables that could be used to predict outcomes of amputation, a cohort of 97 veteran amputees with a median age of 64 years who underwent 155 lower extremity procedures during 1984 was followed for 15 months. A high incidence of postoperative complication, revision, and mortality with poor quality of life confirm the serious prognosis of these individuals. Regression analyses indicated that peripheral vascular disease and prolonged preoperative hospitalization were associated with complications. Preoperative gangrene and peripheral vascular disease were associated with the need for revision. Complications, a low body mass index, and multiple diseases were related to death. Those with multiple diseases and extensive atherosclerosis were less likely to walk. Ability to perform activities of daily living was the most important predictor of quality of life. Patients at higher risk for these adverse outcomes need to be identified early in their hospital stay. The involvement of the patient or his or her surrogate in decisions regarding the course of treatment and the level of amputation is essential.
Pharmacokinetics of cephalothin and cephalexin in selected avian species.
Plasma concentrations and the biological half-lives of cephalothin and cephalexin in avian species of a variety of body sizes and metabolic rates were studied. The species chosen were eastern bobwhite quail (Colinus v virginianus), pigeons (Columba livia), hybrid rosybill ducks (Netta sp), greater sandhill cranes (Grus canadensis tabida), and emus (Dromiceius novaehollandiae). In the 1st phase of the study, cephalothin sodium was given IM in a dose of 100 mg/kg of body weight. Plasma concentrations reached peak (av 18 micrograms/ml) at 0.5 hour and were measurable 2.5 to 5.5 hours after drug administration. The biological half-life of cephalothin was 16 to 54 minutes; the half-life varied directly with increased species body weight, with the exception of the ducks studied. In the 2nd phase, cephalexin monohydrate was given orally in doses of 25, 35, and 50 mg/kg of body weight. Plasma concentrations reached peak (av 20 micrograms/ml) at 0.5 to 1 hour and were measurable 2.5 to 5.5 hours after drug administration. The biological half-life of cephalexin was 36 to 126 minutes. In the 3rd phase, differences in plasma concentrations and the half-lives of cephalexin between fed quail and fasted quail were insignificant. Dosage regimens for cephalothin of 100 mg/kg 4 times a day and for cephalexin of 35 to 50 mg/kg 4 times a day would be expected to establish and maintain therapeutic plasma concentrations in large birds (pigeons, cranes, and emus). These same doses, administered every 2 to 3 hours, would be expected to establish and maintain therapeutic plasma concentrations in smaller birds (quail, ducks).