Biomedical subjects
Publications and source records attributed to S B Lippmann.
Two patients with advanced dementia and severe affective disorders were successfully treated with electroconvulsive therapy (ECT) without significant adverse effects. These reports illustrate that ECT can be effective for depression and mania even when complicated by moderate or severe dementia.
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PURPOSE: To determine the effects of midazolam, 30 ngxmL(-1), on altered perception, mood, and cognition induced by ketamine. METHODS: After ketamine was administered to achieve target concentrations of 50, 100, or 150 ngxmL in 11 volunteers, perception, mood, and thought process were assessed by a visual analog scale. Mini-Mental State examination (MMSE) assessed cognition. Boluses of midazolam, 30, 14.5, and 12 microgxkg(-1), were injected every 30 min to maintain the plasma concentration at 30 ngxmL(-1), which was reached 30 min after each injection. RESULTS: Ketamine produced changes in perception about the body (P < 0.01, 0.001, and 0.0001 at 30, 60, and 90 min), surroundings (P < 0.01 and 0.0001 at 60 and 90 min), time (P < 0.002 and 0.0001 at 60 and 90 min), reality (P < 0.001 and 0.0001 at 60 and 90 min), sounds (P < 0.002 at 90 min), and meaning (P < 0.05 at 90 min). Subjects felt less energetic and clearheaded (P < 0.02 and 0.05) during ketamine, midazolam, and their co-administration. Ketamine impaired thought process (P < 0.003 and 0.0001 at 60 and 90 min). Ketamine and midazolam decreased mean total MMSE and recall scores (P < 0.001 for both). Co-administration reduced the number of subjects with perceptual (body, P < 0.01 and 0.001 at 30 and 60 min) and thought process abnormalities. Within the range of observation, co-administration did not affect the changes in mood or recall. CONCLUSION: Midazolam attenuates ketamine-induced changes in perception and thought process.
A depressed patient was successfully treated with electroconvulsive therapy approximately 7 to 14 days after a cerebellar stroke. This report documents an uncomplicated use of electroconvulsive therapy that was well tolerated and effective in a course of eight treatments in the acute poststroke period.
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When a patient has terminal illness and death is imminent, grief is a normal reaction. Primary care physicians can help patients and their families by talking with them about the five stages of grief (denial, anger, bargaining, depression, and acceptance), providing grief counseling and appropriate pharmacotherapy, and being supportive. Grief often manifests with features similar to those of depression, and it is critical for the clinician to distinguish between the two. One distinguishing feature is that self-esteem in the grieving person is usually uncompromised, whereas a depressed person often has decreased self-esteem. Physicians should also watch for signs of mood disorders or abnormal grief. When grief is present more than 2 months after a loss, a diagnosis of major depression should be considered. Dysfunctional grief accompanied by severe depression and suicidal intent generally calls for psychiatric referral, hospitalization, or both.
Physicians must be alert to the possibility of abuse within the family and home. They should be well prepared to help victims begin the transition to a safer environment. An awareness of the prevalence of abuse and a high index of suspicion are the most effective clinical tools for assisting victims of domestic violence. In addition, physicians need to be familiar with reporting laws in their states. Comprehensive management includes not only treatment but also investigation of injuries, reporting of suspected abuse, referral to appropriate community agencies for violence management or counseling, and addressing underlying chemical dependency or mental disorders. Close follow-up is critical to both detection and prevention. Physicians are obliged not only to treat individuals but also to support social policies that reduce family violence.
Delirium is a common medical condition, especially in elderly hospitalized patients. The syndrome is characterized by a short course of confusion and changes in perception and behavior. Early detection can be enhanced by routine assessment of cognitive functioning in hospitalized patients, especially those at risk for delirium. Prompt recognition and aggressive treatment of the underlying cause are essential for a positive outcome. Supportive measures are designed to calm and protect the patient and provide symptomatic relief until the precipitating condition is corrected.
Alcoholism is a common, chronic, often progressive disorder that has negative effects on a patient's health and severe consequences for society as well. A positive, public health approach that integrates medical, psychological, and social therapies can lead to improved outcomes for patients who abuse alcohol. Physicians can play an important role by educating patients to prevent alcohol abuse from starting, being alert to the risk factors, recognizing the signs of alcoholism (especially during its early stages), and initiating interventions designed to halt progression of this disease. Doctors should maintain a therapeutic stance with patients who have continued to abuse alcohol, even after frequent relapses. Consultation with alcoholism experts may be helpful when treatment is difficult or there is the possibility of a dual diagnosis.
Depression is a common but highly treatable mood disorder. Unfortunately, two thirds of depressed patients may never receive appropriate intervention. Because of individual and societal barriers to the diagnosis, depressive symptoms often go unrecognized. However, primary care physicians are in a unique position to surmount these obstacles by being alert to manifestations of the disorder. Treatment with antidepressant drugs, psychotherapy, electroconvulsive therapy, or a combination of these is very efficacious. The choice of method is based on such factors as history of previous response, severity of disease, concomitant medical illness, and patient preference.
Insomnia may be periodic and transient, as caused by situational stress, or persistent, as caused by a chronic sleep disorder. Physicians can gain much information concerning the type, probable cause, onset, and duration of insomnia through history taking. A sleep diary may reveal helpful information, and input from the patient's sleeping partner can also be valuable. Complicating disorders, such as heart failure, prostatism, or depression, should be sought and specific treatment prescribed. Chemical dependency, too, requires appropriate treatment. These measures, institution of good sleep-hygiene practices, and behavior modification may resolve sleeplessness. The primary indication for use of hypnotic agents is transient sleep disruption caused by acute stress. When an agent is chosen, onset of action, metabolism, and side effects should be considered, especially in elderly patients. Addictive agents should not be given to patients with substance abuse problems. If insomnia persists, evaluation at a sleep-disorder center is recommended to facilitate design of an appropriate therapeutic regimen.
Electroconvulsive therapy (ECT) efficacy is related to the stimulus intensity and clinically associated with the duration of the induced seizure. Convulsions lasting 30 to 60 seconds are conventionally considered to be of optimal length, and generally are achieved by applying routine ECT technique. An ictus slightly shorter or longer is usually also therapeutically satisfactory. In our study, seizures lasting between 30 and 60 seconds produced a favorable clinical outcome. A very similar effect was observed in all cases where the duration was within 16 to 120 seconds. However, subjects experiencing intal periods of less than 15 seconds and those over 120 seconds resulted in less favorable response. Detailed records as to medicinal and electrical stimulus doses, seizure timings, etc, were excellent guides for subsequent ECT to achieve appropriate convulsion durations and a safe, satisfactory outcome.
The purpose of this study was to measure alterations in the level of disruptive patient activity on a locked psychiatric unit after initiation of a smoking ban. Most of the monitored parameters of disruptive behavior remained stable, and/or changes did not reach statistical significance after the implementation of the smoking prohibition. This is in agreement with previous investigations. The only exception was an increase in the amount of p.r.n. medications dispensed specifically for agitated behavior [t(8 df) = -3.07 (p = 0.015)]. Though major clinical disturbances did not occur, it appeared that patients experienced a small yet documentable increase in agitation. Despite there being no major problems in establishing a smoke-free psychiatric service, abolishing tobacco products may create some minor management difficulties. This may be most commonly observed on locked units that treat large numbers of severely disturbed, involuntarily hospitalized individuals.
When phobias compromise a person's normal lifestyle or cause ongoing anxiety, they must be dealt with. Irrational, persistent fears may lead to isolation, depression, even substance abuse. What are the features of agoraphobia? Social phobia? Simple phobia? How common are these anxiety disorders? The authors answer these questions and discuss differential diagnosis and treatment options.
A case of clozapine-induced agranulocytosis that was treated with a granulocyte colony-stimulating cytokine is presented. The hematological status normalized. Two colony-stimulating factors are marketed for activating bone marrow function. Their utility in clozapine a granulocytoses is not clear, but they offer a potential new therapeutic option.
The presence of HIV spectrum illness stimulates a powerful emotional reaction from a patient's family and friends. Grief and shock over the infection, and its implications are frequent observations. Sadness, anxiety, helplessness and anger are also common. Health care staff should address these responses in order to strengthen coping skills and maximize interpersonal comfort. Stigmatization and isolation are major stressors. Bereavement is complicated by fear, shame, dependency and hopelessness. Therefore, a task in counselling is to maintain the integrity and supportiveness of the patient's social unit by encouraging open communications between those involved and by educating about AIDS. Information should be provided on HIV transmission, self-protection, and illness progression as well as the safety of causal contacts and the practices of 'safer sex'. The significant others should retain outside interests and be encouraged to seek help for patients from supportive social agencies. Instillation of hope lends benefit to patient, family and friends. Kind, non-judgmental counselling and good quality medical care should be made available, especially since HIV-related disorders are increasingly becoming a chronic disease. Advocacy for the significant others translates into better adjustment and it enhances the patient's medical prognosis.
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