Biomedical subjects
Publications and source records attributed to M Sacks.
We report a patient with progressive systemic sclerosis in whom an autopsy, performed 13 years after diagnosis, revealed the presence of bronchioloalveolar carcinoma and of generalized amyloidosis. Characterization of the amyloid fibril protein suggested an immunoglobulin light chain (AL) origin.
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Serological testing of waste bloods revealed that 25 (7%) of 350 acutely ill psychiatric inpatients had HIV infection. Eight of the 10 HIV-positive patients whose serological status was not recorded on admission were discharged with their status still unrecorded and presumably undetected. Thirty-nine (51%) of the 77 inpatients with HIV-related risk behaviors identified on admission were discharged with no record of their having been serologically tested before or during hospitalization.
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Although effective medications for the treatment of Axis I disorders have been developed, achieving adequate, let alone, optimal medication regimens has been difficult. This hypothesis-generating study had the objective of dissecting the process of medication-management among 24 previously hospitalized affective disorder patients, their families, and their doctors in Italy, Japan, and the United States as well as identifying their outcomes. The data demonstrated significant positive associations between outcome and delivery of adequate medication as well as psychoeducation (about the illness and its treatment) to both patient and family. These results suggested that, regardless of country, medication was necessary but insufficient without the practitioner delivering a family intervention and psychoeducation.
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Recent research suggests that, despite the development of effective psychiatric treatment, there is marked underuse of care. This pilot study had the objective of dissecting the process of care in an attempt to understand outcomes for patients with major affective disorder and for their families. Twenty-four patients with a DSM-III diagnosis of major affective disorder were identified 12 to 18 months after hospital admission in three countries (Italy, Japan, and the United States). The patients, their families, and their doctors were interviewed separately and then together, using instruments measuring delivery of treatment (using an ideal treatment criteria set) and percentage of achievement of treatment goals. These measures were then (using parametric and nonparametric statistics) correlated with resolution of the index episode and the patient's global outcome (using the Global Assessment Scale). The data demonstrated that physicians delivered about half (52%) and, subsequently, achieved about half (54%) of what would be considered ideal care to patients and other family members. The mean resolution of the index episode at follow-up was only 3.0 (on a 0- to 5-point scale). There was a significant positive association between the most important outcome measure, i.e., the resolution of the episode, and the achievement of treatment goals for both the patient (p less than .07) and the family (p less than .005). Patients and families with the best resolutions received significantly more good treatment than those with the worst resolutions (p less than .02), most notably with regard to medication (p less than .002).
One hundred and eighty-one cases of primary small intestinal lymphoma were diagnosed in residents of Israel--145 Jews and 36 Arabs--during a 16-year period, 1960--75. The male:female ratio was 1.8:1. Incidence rates were higher in children, the middle-aged and the elderly than in teenagers or young adults. Crude and age-adjusted incidence rates were higher in Arabs than in Jews. The pattern among the subgroups of the Jewish population varied with age. In young adults of both sexes the rates were much higher among Jews born in North Africa or Asia than among those born in Europe or Israel. In elderly males, however, the rates were almost twice as high in European-born Jews than among those born in North Africa or Asia. The mean annual incidence of primary small intestinal lymphoma fell from 4.8 per million during 1960--67 to 3.6 per million during 1968--75. This was due to a marked fall in the rates in children and young adults, whereas the rates in those aged 40 years or more rose with time. The pattern of the change with time suggests that environmental conditions are an important factor in the causation of primary intestinal lymphoma in young adults.
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Operations at the clinical-research interface exert a signal influence on the therapy of patients being treated on investigative units. The effect on the treatment milieu has been described but the impact of a research climate on individual psychotheraphy of hospitalized patients has not. We observed research-therapy interaction in 25 acutely schizophrenic patients. Analytically oriented psychotherapy was carried out on a National Institutes of Health clinical research unit where drugs are only occasionally used, and patients are subjects in psychobiological investigation. The subtle, and often neglected, interplay between therapy and research is examined, with emphasis on the shifting meanings of the patient's participation or refusal to participate in therapy, research, or both. A research transference and countertransference are defined, and some special behavioral patterns of research patients receiving dynamic therapy are considered in this framework.
A group pf 19 acute, medication-free schizophrenic patients was studied, using average-evoked responses (AERs) to four intensities of light. Comparison with age- and sex-matched normal controls and patients with bipolar affective disorders showed that schizophrenics had smaller AER amplitudes and either no increase or an actual decrease in amplitude with increasing stimulus intensity. Normal subjects and schizophrenic patients were discriminated with 71% accuracy using AER variables; normals, patients with bipolar disorders, and schizophrenic patients with 64% accuracy. Patients who evidenced this AER "reducing" pattern to a noticeable extent early in hospitalization showed greater improvement and tended to have relatively good premorbid histories.
The authors describe their experience in carrying out clinical and psychobiological research in a therapeutic milieu setting. The clinical-research meeting, composed of clinical-care staff with secondary research responsibilities, researchers, and acutely psychotic patients, proved to be a useful mechanism for identifying and resolving inevitable problems at the clinical-research interface and enhanced the effectiveness of research implementation and patient care. The authors discuss three specific areas where covert issues threatened to undermine the work of the unit-the abrogation of research responsibility, the abrogation of clinical responsibility, and intergroup competition and envy.
Digitalis is a ubiquitous drug in modern clinical medicine and digitoxicity is one of the more common iatrogenic disorders. Psychiatric problems are often overlooked as manifestations of digitalis excess and may range from mild disorientation, lethargy, or restlessness to full blown delirium. In this paper we discuss two patients who presented to a psychiatric inpatient unit and were later found to be digitoxic. Psychiatrists are advised to consider digitalis as a possible cause of mental abnormalities and are reminded that psychiatric signs may be the first indication of a potentially lethal drug toxicity. Psychiatric patients may also be at special risk for the development of digitoxicity because of erratic drug taking, electrolyte imbalance or increased autonomic tone.