Primary Medical Conditions Research Articles

Medical problems and oral care of patients with Down syndrome: a literature review

When planning the dental treatment of patients with Down syndrome (DS), dental practitioners should always consider their general health, in order to achieve a holistic and interdisciplinary approach. This article presents a literature review of the primary medical conditions in patients with DS that may affect their general health care and the appropriate clinical delivery of oral health care.

Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

As international scholars of catatonia, we are concerned that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) proposes to delete the codes 295.2 (schizophrenia, catatonic type) and 293.89 (catatonia secondary to a medical condition) and to substitute a noncoded "catatonia specifier" as the principal identifier. We believe that these changes will badly serve clinical practice and research. We advocate a unique and broadly defined code for catatonia in DSM-V. Catatonia is common among hospitalized psychiatric patients, including adults, adolescents, and occasionally children. In the 10 principal prospective studies from sites around the world, catatonia syndrome was identified in a mean (SEM) percentage of 9.8% (1.4%) of adult admissions (Table 1). These patients have multiple signs of catatonia (commonly >5); 68% (6%) are mute, and 62% (3%) are negativistic or withdrawn. Some are unable to eat, requiring parenteral nutrition and/or medication.TABLE 1: Prospective Studies of the Incidence of CatatoniaOnce catatonia is recognized, first-line treatment with benzodiazepines usually brings prompt relief, although high doses may be needed. If catatonia persists, electroconvulsive therapy is often rapidly beneficial. Every prospective study confirms that catatonia syndrome exists, occasionally becomes malignant, and requires prompt treatment. Under the proposed new guidelines for DSM-V, patients with catatonia syndrome will lack an informative diagnosis. Mutism, negativism, and withdrawal prevent assessment for mood, cognitive, and psychotic symptoms and impede proper delineation of episodes of prior illness. Without findings for a specific diagnosis, it is rational to use a provisional diagnosis of the catatonia syndrome to allow tests and treatments to proceed. Lacking recognition and treatment, catatonia may persist or worsen with adverse or life-threatening results. On the other hand, when patients with catatonia are identified and treated, they become verbal and interactive, allowing interviews and more definitive diagnoses, regardless of the primary pathological findings. When patients cannot provide information, clinicians may conflate or misdiagnose catatonia with schizophrenia (as in the DSM-IV schema), impute a psychotic process, foster the unproven use of neuroleptics, and risk adverse effects, such as conversion to malignant catatonia or the neuroleptic malignant syndrome. Similarly, assignment of catatonia to "psychosis not otherwise specified" (298.9, DSM-IV and DSM-V) would be erroneous because these patients often either lack hallucinations and delusions or cannot be assessed for them. The proposed elimination of DSM-IV "catatonia due to a general medical condition" (293.89) renders the coding for catatonia arising from general medical conditions problematic. At clinical presentation, the medical/toxic factors are rarely known, as time is often needed to identify these etiologies. We also note that noncoded specifiers are not useful for research on nosology, treatment, and outcome. To address all these issues, we urge inclusion in DSM-V of a specific diagnostic code for catatonia. One simple option is to retain the 293.89 code but revise its formulation to broadly encompass the catatonia syndrome without imputing a link to either primary psychiatric or general medical conditions. A unique and broadly defined code would foster recognition of the catatonia syndrome and permit research on nosology, treatment, and outcome. These goals are not met with the DSM-V plan for noncoded modifiers.

Sleep disturbances in Parkinson's disease

Sleep disturbances are very common in patients with PD and are associated with a variety of negative outcomes. The evaluation of sleep disturbances in these patients is complex, as sleep may be affected by a host of primary sleep disorders, other primary medical or psychiatric conditions, reactions to medications, aging or the neuropathophysiology of PD itself. In this article, we review the evaluation of the common disturbances of sleep seen in PD. This includes the primary sleep disorders, the interaction of depression and insomnia, the impact that medications for PD have on sleep, as well as the role of factors such as nocturia, pain, dystonia, akinesia, difficulty turning in bed, and vivid dreaming. The treatment of sleep disturbances in PD is largely unstudied but recommendations based on clinical experience in PD and research studies in other geriatric populations can be made. Important principles include, diagnosis, treating the specific sleep disorder or co-occurring disorder, and control of the motor aspects of PD.

Skin and psyche: Diversionary symbiosis

A significant proportion of patients with skin diseases have associated psychosocial factors. Not only does psychopathology manifest on the skin in absence of any real skin disease, primary skin disorders can also be exacerbated by emotional stress adversely influencing the homeostasis of immunological and inflammatory processes in deeper layers of the skin. Furthermore, many patients develop emotional problems as a result of having disfiguring skin diseases. In addition, some patients having solely sensory disturbances in absence of primary dermatoses or identifiable medical or neurological conditions, as well as some purely dermatologic conditions such as post-herpetic neuralgia may preferentially need psychotherapeutic modalities to address their underlying psychopathology irrespective of the presenting dermatologic manifestation arising out of ‘somatisation’ of a psychopathology into physical problems. The most obvious course of action of referral to a psychiatrist or another mental health professional may unfortunately not be readily tenable either due to the perceived stigma associated with psychiatric illness or lack of insight on the part of patients. In the interregnum, effective management of the psychologic or/and psychiatric problems can only be done by the dermatologist provided he has an adequate knowledge base and experience to undertake psychotherapeutic modalities.

On the Resurgence of the Hematologist as Consultant to Primary Care Practitioners.

The widespread use of “routine” automated blood testing in primary care practice appears to have increased the demand for consultative services by hematologists. To explore this hypothesis, we tracked consecutive first-time referrals to our university hospital hematology clinic retrospectively between July 2002 and June 2003 and prospectively from July 2003 to May 2004. Findings were similar in both time intervals and thus are combined for reporting. Of 557 consultative referrals, 326 patients (58.5 %) were referred for abnormalities of the peripheral blood counts, 209 (64%) of which were detected as incidental findings in asymptomatic patients. 144 (26%) of all referrals were for anemia and 79 (55%) of those proved to have primary medical conditions including active alcoholism, medication effects, chronic renal failure, iron deficiency, chronic inflammatory diseases or advanced liver disease. The rest had hematological disorders including, myelodysplastic syndromes, hemoglobinopathies, hemolytic anemias, and others. 66 (12%) of all referrals were for abnormalities of the white blood cell count and only 24 (36%) turned out to have a primary hematological disorder (e.g. CLL, CML or benign chronic leukopenia). The other 42 (64%) had primary medical disorders including leukocytosis of smoking or pregnancy, allergies, anti-convulsant-related leukopenia, etc. 50 patients were referred for thrombocytopenia or thrombocytosis, of which 29 (58%) had primary medical disorders including iron deficiency or inflammatory states, gestational thrombocytopenia, known hypersplenism, medication-related thrombocytopenia, or alcoholism. Similarly 20 of the 40 patients referred for bi- or pancytopenias had primary hematological disorders and 20 had medical disorders that included hypersplenism, drugs, or mild disorders that resolved by the time of referral. The remaining 231 patients (41.5%) included 69 who were referred for evaluation of, and counseling for, hypercoagulable disorders, 39 referred for presumed bleeding disorders (4 had senile purpura; 9 had storage pool disorders), 9 with hereditary hemochromatosis, 51 with hematological malignancies, 12 with unexplained lymphadenopathy (8 with infectious mononucleosis or other reactive lymphadenopathy, 1 with enlarged tonsils, 1 CLL, 1 T-cell lymphoma, 1 Kimura's disease) and 9 patients with polyclonal hyperglobulinemia. Overall, only 45 % of the patients referred for consultation turned out to have a primary hematological disorder. The rest had conditions that are traditionally considered to be in the realm of internal medicine or primary care. Most consults were initiated based on incidental abnormalities of the CBC that were not, or could not be, worked up by the referring physician. Thus primary care practitioners are relying on hematologists to explain routine findings in often-asymptomatic patients with fortuitous abnormalities of the peripheral blood counts. Medical surveillance of asymptomatic patients is likely to result in progressively early detection of subtle changes in the CBC that internists and others will rely on hematologists to explain. Thus the hematologist's role as consultant continues to expand.

Quantifying the harmful effect of psoriasis on health-related quality of life

Background: Psoriasis affects 7 million people in the United States, causing substantial cost, social stigma, and disability. Objective: The purpose of this study was to evaluate the health effects of skin disease by comparing psoriasis to other primary medical disorders using 3 different scales of health-related quality of life. Methods: A self-administered questionnaire consisting of 3 health-related quality of life measures was given sequentially to 35 eligible patients with psoriasis presenting to the Dermatology Branch of the National Cancer Institute (NCI) for an investigational therapeutic protocol. Results: All patients (100%) agreed to participate. The median Psoriasis Area and Severity Index (PASI) score was 13.0. Overall, 82.9% at least often felt the need to hide their psoriasis, and 74.3% claimed their self-confidence was at least often affected by their psoriasis. The median EQ-5D health state utility score was 13.0% less than healthy individuals (P < .001). On the SF-36, the mean general health score was 13.2% less (P = .005) and the median social functioning score 18.7% less (P = .005) than that of patients with no chronic conditions. Conclusion: Individuals with psoriasis are significantly affected in their health state utility, perception of general health, and social functioning when compared with individuals without chronic disease and those with certain primary medical conditions. (J Am Acad Dermatol 2002;47:512-8.)

Assessment and treatment of sensory- versus motor-based feeding problems in very young children

The identification of abnormal oral-motor patterns in infants and children with neuromuscular disorders has been well documented. Poor feeding skills in children with cerebral palsy have required early treatment, and a neurodevelopmental treatment approach has frequently been used. With advances in medical technology, infants of younger gestational ages and with more complicated diagnoses are surviving. The course of hospital treatment for these infants may be lengthy and intensive. On discharge some premature and full-term infants, whose primary medical conditions have resolved and who have no evidence of cerebral palsy or other oral-motor dysfunction, may present with an oral feeding aversion of unknown etiology. When oral intake is inadequate, supplemental tube feedings may be required. The authors hypothesize that these infants and children suffer from abnormal oropharyngeal sensory perception. This article discusses the assessment and treatment of such sensory-based oral feeding disorders.

Impact of neuropharmacology in the 1990s — treatment strategies for anxiety disorders and insomnia

Effective management of insomnia begins with recognition and adequate assessment. Family doctors and other health care providers such as practice nurses and psychologists should routinely enquire about sleep habits as a component of overall health assessment. Identification and treatment of primary psychiatric disorders, medical conditions, circadian disorders, or specific physiological sleep disorders—eg, sleep apnoea and periodic limb movement disorder—are essential steps in management of insomnia. Conditioned aspects of insomnia can be primary (psychophysiological insomnia) or may complicate sleep disturbance owing to other causes. Approved hypnotic drugs have clearly been shown to improve subjective and objective sleep measures in various short-term situations. Despite widespread use of standard hypnotics and sedating antidepressants for chronic insomnia, their role for this indication still remains to be further defined by research evidence. Non-pharmacological treatments, particularly stimulus control and sleep restriction, are effective for conditioned aspects of insomnia and are associated with durable long-term improvement in sleep.

Dobutamine pharmacokinetics and pharmacodynamics in pediatric intensive care patients.

To evaluate the pharmacokinetics and pharmacodynamics of dobutamine in critically ill children. A prospective study of pediatric patients receiving continuous infusions of dobutamine in a stepwise format from 2.5 to 10.0 micrograms/kg/min. A pediatric critical care unit. Twelve children ranging in age from 1 month to 17 yrs with primary medical conditions. Plasma dobutamine concentrations and hemodynamic responses were measured at each infusion rate at steady state. Dose response data were analyzed to determine the threshold or minimum plasma dobutamine concentration necessary for discernible hemodynamic effects. Dobutamine plasma clearance rates ranged from 40 to 130 mL/kg/min. Each patient presented a linear increase in the plasma dobutamine concentration at each infusion rate (r2 = .97, p less than .001). Plasma clearance rate vs. actual dobutamine concentration did not vary. Cardiac output, BP, and heart rate increased 30%, 17%, and 7%, respectively, at maximal dose. The dobutamine concentration thresholds for changes in cardiac output, BP, and heart rate were 13 +/- 6, 23 +/- 14, and 65 +/- 30 ng/mL, respectively. There was no effect of plasma dobutamine concentration or infusion rate on plasma clearance rate. For this group of patients, over the range of the intravenous doses studied, dobutamine pharmacokinetics followed a first-order kinetic model. Threshold values for dobutamine usually show increases in cardiac output before changes in heart rate. These data demonstrate that dobutamine is an effective inotropic agent in critically ill pediatric patients and has minimal chronotropic action.

The Relationship of Antibody-Coated Bacteria to Clinical Syndromes

In selected patients, detection of antibody-coated bacteria (ACB) in voided urine has correlated with upper urinary tract infection. From unselected patients, we studied 350 consecutive urine specimens submitted to the diagnostic laboratory with colony counts greater than or equal to 10(5)/ml. In 19% (55) among 288 specimens selected for final analysis ACB occurred. There were no substantial differences in the occurrence of ACB by age or sex of patients or by species of bacteria. The relationship of ACB to clinical syndromes was: asymptomatic bacteriuria, 15% (27/178); cystitis, 8% (6/75); acute hemorrhagic cystitis, 67% (4/6); prostatitis, 67% (2/3); and acute pyelonephritis, 62% (16/26). Among seven clinical findings, only structural abnormalities of the upper urinary tract correlated with the presence of ACB. Failure of fever and leukocytosis to correlate with ACB probably reflected the presence of other associated primary medical or surgical conditions.