1/26. Chronic addiction relapse treatment: a study of the effectiveness of the high-risk identification and prediction treatment model. Part II. The HRIPTM case table, case study examples and questionnaire.The high-risk identification and prediction treatment model (HRIPTM) was developed to investigate the physiological and psychological conditions associated with the concept of negative emotional state, and to examine the origin and evolution of this condition in relation to addiction relapse. An in depth case study sample of n=30 was conducted within the context of an intensive outpatient addiction treatment program based on the HRIPTM. The HRIPTM investigates the nature of problematic repetitive behavior patterns originating in the childhood developmental period, the individual nature of negative emotional state in relation to these patterns and their evolution, and their influence on addiction vulnerability and addiction relapse. The preliminary study upon which this model was based emphasized the importance of developing methods for accumulating information that pinpoints lifespan experiences associated with the origin of problematic behaviors, the level of emotional intensity factors associated with behavior pattern construction and development, and level of associated risk potential as it manifests in each individual case.Recent neuroscientific studies into the early developmental process are producing increased evidence of the enormous influence of this period on later developmental processes. Addiction, in itself a developmental process, may be more influenced by pre-addiction factors than previously assumed. This model addresses those influences. The study was conducted to determine whether or not information that arises from the HRIPTM increases the patient's and clinician's ability to address addiction relapse more effectively. As a result of completion of the HRIPTM program, the sample n=30 reported gained ability to address recovery processes more effectively. The 12-question HRIPTM Questionnaire instrument, when tabulated, revealed that of the 360 total responses, less than 2% disagreed that ability had been gained in all suggested areas defined in the questionnaire. Over 98% agreed or strongly agreed that ability had been gained in the defined areas.- - - - - - - - - - ranking = 1keywords = nature (Clic here for more details about this article) |
2/26. hypercalcemia and human nature.patients on hemodialysis may develop severe and symptomatic hypercalcemia if skeletal buffering is ineffective. We report a case of persistent hypercalcemia with apparent extrarenal vitamin d synthesis. Associated aluminium intoxication was suggested on desferrioxamine challenge and adynamic uremic osteodystrophy confirmed on bone biopsy. plasma calcitriol did not suppress with corticosteroids but did with ketoconazole. No other evidence for underlying granulomatous disease was found. We discuss our approach to less usual causes of hypercalcemia, and emphasise the pitfalls associated with factitious disorders.- - - - - - - - - - ranking = 2keywords = nature (Clic here for more details about this article) |
3/26. Management of the difficult patient with complex partial seizures.Successful treatment of partial complex seizures (and the epilepsies in general) is a process of management over time and involves several factors. It starts with accurate and adequate diagnostic formulations. To this end the physician must be thoroughly familiar with the ictal manifestations of partial complex and other epilepsies as well as the clinical features of other transient but reversible episodes that might present difficulties in differential diagnosis. The diagnosis is based upon the history of a patient experiencing partial complex seizures, and the most important resource is a careful and detailed history of the ictal events and the circumstances under which they occur. Clinical observation and electrophysiologic monitoring of the patient during attacks, either spontaneous or induced, is the most powerful technique available in cases which present difficult diagnostic problems. In addition to recognition and proper classification of the seizures themselves, diagnosis and treatment of the cause of the seizures, particularly when it is an active disease, is of prime importance. Even after accurate diagnosis, the heterogenous nature of the population of patients with partial complex seizures is such that marked variation in response to treatment with antiepileptic drugs is to be anticipated. The use of these drugs must be individualized and based upon a thorough and working knowledge of their clinical pharmacology. The most frequent mistakes in our experience have been prescribing the drugs in too little doses or for too short a time. Less often the problem is overmedication. The best indicator of the effectiveness of the drugs is the clinical response of the individual patient, and in general each drug should be prescribed in increasing doses until either the seizures are controlled or unacceptable degrees of toxicity develop. The use of serum level determinations can be very helpful if not invaluable, particularly in identifying and understanding potential adverse effects of the drugs. Patient noncompliance in adhering to drug schedules is widespread, but usually can be detected by measuring serum levels. Even with the most efficient use of the drugs, however, some patients will be intractable, and elective surgical treatment should be considered. Finally, control of seizure occurrence alone is not necessarily adequate treatment, as many patients will have difficult psychosocial problems associated with their epilepsy. Treatment of such associated problems is necessary on its own merits, but occasionally can result in significant improvement in seizure control.- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
4/26. Limb-body wall complex: a case series.OBJECTIVE: Limb-body wall complex (LBWC) is a rare fetal polymalformation of uncertain etiology, but it has been regarded as sporadic in nature with a low recurrence risk. We review a case series in light of recent evidence about possible genetic and environmental associations. methods: All abortions or births coded as limb-body wall defect or fetal acrania/exencephaly or with unclassified polymalformation between January 1996 and January 2001 were audited. RESULTS: During the 5-year period there were 33,286 live births in our region. Eleven cases met the criteria of LBWC giving an incidence of 0.33/1000 live births. In 50%, 50% and 30% of women a history of cigarette, alcohol and marijuana use, respectively, was noted. Furthermore, 40% of the women had a history of a previous infant with a congenital anomaly. One patient delivered two consecutive male infants with LBWC. CONCLUSIONS: Whilst the majority of cases of LBWC are sporadic, some women may have an underlying genetic predisposition. It may be prudent to advise against the use of alcohol, cigarettes and other drugs and to offer an ultrasound scan in a tertiary referral center in a subsequent pregnancy.- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
5/26. Myoclonic encephalopathy caused by chronic bismuth abuse.bismuth (Bi) is used for the treatment of different gastrointestinal symptoms and disorders such as gastric ulcers. In germany, Bi medication is available without prescription as over-the-counter-medication even though it can cause severe myoclonic encephalopathy if ingested chronically in high doses. We report a 49 year-old woman with chronic gastric ulcers and 5 years of Bi abuse who developed the typical clinical course of Bi encephalopathy. She presented with progressive dementia, dysarthria and myoclonic jerks one week after increasing the Bi dosage. The EEG showed generalized spike-wave complexes suggesting that the myoclonus was epileptic in nature. Bi intake was stopped and valproate was given, which decreased the frequency of the myoclonic jerks. Administration of the metal chelator D,L-2,3-dimercaptopropane- 1-sulfonic acid (DMPS) led to increased urine excretion of Bi, but was accompanied by a clinical deterioration which resulted in it being discontinued. The subsequent clinical recovery of the patient was documented over 40 days by EEG, video and neuropsychological testing. A time lag of two weeks was observed between falling plasma levels and clinical improvement. In conclusion, Bi-induced encephalopathy is a differential diagnosis for myoclonic encephalopathies. Treatment with metal chelators may aggravate the encephalopathy. The over-the-counter availability of medications containing Bi should be questioned. (Published with video sequence.)- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
6/26. Defining dual diagnosis of mental illness and substance misuse: some methodological issues.This paper discusses methodological issues arising in the initial stages of a larger epidemiological case-control study. Practitioners from both Generic mental health and Substance Misuse Services (n = 170) were asked to identify which of their clients, from a time-limited caseload (n = 2341), had comorbid mental health and substance misuse problems. Although practitioners were provided with a definition of 'singly diagnosed' and 'dually diagnosed', it became apparent that these definitions were applied pragmatically, depending on the nature of the client's primary problem and the agency they were presenting to. Issues raised include the time period in which a client was considered to have a concurrent mental health problem and substance misuse, how a 'mental health problem' was defined and whether a personality disorder should be categorized as a 'mental health problem'. There was also some disagreement about whether clients who were being treated primarily by Substance Misuse Services, but were also taking prescribed antidepressants, implicitly had a 'mental health problem'. We raise these methodological issues, as they have implications for determining the prevalence of 'dual diagnosis' and the subsequent provision of services.- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
7/26. Lethal injuries occurring during illegal break-ins.Individuals who undertake criminal activity are often at risk of injury for a variety of reasons. Two cases are reported where individuals who were engaged in illegal breaking and entering activities sustained stab wounds from broken window glass and died of exsanguination. The cases both involved young males who were under the influence of alcohol and/or drugs and who sustained relatively minor tissue damage that had fatal consequences due to a variety of coincident factors. Critical location of wound sites over major vessels resulted in rapid bleeding that was enhanced by vasodilator effects of alcohol and stimulant effects of amphetamines. In addition, adrenergic effects of being engaged in illegal activities, and the subsequent pain from the wounds, may also have contributed to accelerated heart rate and blood loss. Failure to appreciate the potential effects of such wounds, which may initially have appeared relatively minor based on their small size, added to an impaired ability to apply first aid or seek appropriate medical assistance, may also have been due to the combined effects of drugs, alcohol, and concerns regarding the illegal nature of the underlying activity. Such a scenario constitutes a specific subgroup of offender injury that could be termed the break, enter, and die syndrome.- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
8/26. Protracted withdrawal syndromes from benzodiazepines.The benzodiazepine withdrawal syndrome is a complex phenomenon which presents serious difficulties in definition and measurement. It is particularly difficult to set out precise limits on its duration. Many withdrawal symptoms are a result of pharmacodynamic tolerance to benzodiazepines, some mechanisms for which are discussed. Such tolerance develops unevenly in different brain systems and may be slow to reverse. Withdrawal symptoms occurring in the first week after cessation of drug use tend to merge with more persistent symptoms that may last for many months. These prolonged symptoms do not necessarily constitute "true" pharmacological withdrawal symptoms, but are nevertheless related to long-term benzodiazepine use. Such symptoms can include anxiety, which may partly result from a learning deficit imposed by the drugs, and a variety of sensory and motor neurological symptoms. The protracted nature of some of these symptoms raises the possibility that benzodiazepines can give rise not only to slowly reversible functional changes in the central nervous system, but may also occasionally cause structural neuronal damage.- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
9/26. Deteriorating epilepsies: severely deteriorated cases.A total of 28 cases of severely deteriorated epileptic patients were seen at out- and inpatient services in the past 12 years. In 22 out of these 28 cases, the etiology for the deterioration was considered to be due to either repetitive intractable seizures or antiepileptic drugs (AEDs) or both. Although differential diagnoses were difficult in many cases as to the responsible causes, namely seizure vs. AEDs, it was considered in 6 cases that AEDs took a major role in their deterioration. Details of such cases are presented. Special emphasis was made to the fact in which they frequently showed episodes of acute or ataxia and confusion often associated with febrile illness. They took a course of acute or subacute exacerbation and partial remission. Discussion was held on the nature and possible avoidance of these deteriorations.- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
10/26. From basic concepts to clinical reality. Unresolved issues in the diagnosis of dependence.This chapter discusses clinical and conceptual issues pertaining to the diagnosis of alcohol and drug dependence. Emphasis is given to the difficulties involved in moving from diagnostic concepts, such as those contained in the major psychiatric classification systems, to the clinical situation where diagnostic decisions are made. To illustrate how diagnostic concepts approximate clinical reality, a set of case histories is used to organize a discussion of unresolved issues in the diagnosis of dependence. These issues include the putative syndrome nature of dependence, the problem of diagnosing polysubstance use, the primary-secondary distinction, the presence of other psychopathology, and the use of multiaxial evaluation.- - - - - - - - - - ranking = 0.5keywords = nature (Clic here for more details about this article) |
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