SUNY Upstate Medical University Research Articles

Subdural evacuating port system (SEPS)—Minimally invasive approach to the management of chronic/subacute subdural hematomas

ObjectiveThe population suffering from chronic/subacute subdural hematomas (SDHs) generally includes elderly patients with co-morbidities; therefore the success of less invasive surgical techniques has been of long standing interest. The optimum treatment option for chronic/subacute SDH has not been well established. We report our retrospective outcomes of SDH drainage through a subdural evacuating port system (SEPS). Patients and methodsFifty-two consecutive adult patients with chronic/subacute SDH treated with SEPS (total 64 procedures), over a period of 3years (June 2006–June 2009), were included. 9/52 patients had SEPS performed for bilateral SDHs. Three patients had SEPS placed for recurrent SDH. This retrospective study was approved by the Institutional Review Board of SUNY Upstate Medical University and Crouse Hospital. ResultsOverall 38/52 patients (73%) showed clinical improvement, 10/52 patients (19%) did not show any clinical improvement and 4/52 (8%) patients became clinically worse after the SEPS placement during initial hospitalization. 41/52 patients, treated initially with SEPS were followed as outpatients. 32/41 patients improved, returning to baseline neurological status, 5/41 patients improved, but still had some residual symptoms. The remaining 4/41 patients, presented with recurrent symptoms and had recurrent SDH on CT scans. During the in-hospital post-SEPS period, 8 SDH had >75% decrease, 17 SDH had between 50 and 75% decrease, 23 SDH had between 25 and 50% decrease and 14 procedures had <25% decrease in maximal width of the SDH on postoperative scans. Outpatient follow up CT scans after SEPS placement were available for 46/64 procedures. At final outpatient follow up, 33/46 SDHs showed >75% decrease in maximal thickness, 4/46 SDH showed between 50 and 75% and 2/46 SDH showed between 25 and 50% decreases in maximal width of chronic SDH. However, in 7/46 patients, SDH re-accumulated (i.e. increased in thickness) as outpatients, after initial response to treatment on post-operative in-hospital CT scans. ConclusionSEPS is an effective, relatively safe and convenient treatment strategy with low invasiveness; among management options of chronic/subacute SDH.

Platelet Transfusions and Bleeding Complications Associated with Plasma Exchange Catheter Placement in Patients with Presumed Thrombotic Thrombocytopenic Purpura

Abstract 1162▪▪This icon denotes a clinically relevant abstract Introduction:Since the advent of plasma exchange, mortality from thrombotic thrombocytopenic purpura (TTP) has gone from approximately 90% to less than 20%. However, due to thrombocytopenia, placement of a central venous catheter for plasma exchange can cause concern on the part of the proceduralist. Traditional teaching has been that platelet transfusion is contraindicated in TTP unless there is severe bleeding. However, a more recent review shows that the evidence for harm from platelet transfusion is uncertain. Due to the risk of bleeding, proceduralists often ask for platelet transfusion before catheter insertion. We conducted a review in our institution of bleeding episodes after cathether insertion in patients with suspected TTP. Methods:A single institution retrospective review was performed at SUNY Upstate Medical University on patients with presumed TTP from January 1999 until July of 2011. Patients were identified using both pheresis records and diagnosis codes of admitted patients in order to ensure that patients with catastrophic bleeding episodes prior to plasma exchange were not omitted. Each event was defined as placement of a pheresis catheter in a patient who presented with presumed TTP. Data was collected on patient age, platelet count prior to line insertion, the service performing the insertion, use of image guidance, bleeding complications, and survival. Results:There were 55 patients with a total of 57 catheter insertion attempts in thrombocytopenic patients with presumed TTP. One patient had an unsuccessful insertion attempt and another had catheter malfunction; both required a second insertion attempt while thrombocytopenic. Overall there were no major bleeding complications and no bleeding that required invasive intervention or removal of the catheter. There were 3 episodes of bleeding that resolved with pressure. Otherwise, there was minor bleeding that did not require any intervention documented in 14 cases. These included oozing, saturation of dressing, and 6 hematomas which did not require treatment. There was a single unsuccessful attempt at blind catheter placement which resulted in a hematoma.The median platelet count on catheter insertion was 26K with a range from 3K to 128K. Platelet transfusion was given prior to catheter placement in 14 of the episodes. The median platelet count in this population was 12K before transfusion. 5 of these 14 patients had minor bleeding complications (35%). In the 43 attempts in patients who did not receive platelet transfusion prior to line insertion, the median platelet count was 25K. 12 of these patients had minor bleeding (28%). All 3 patients with minor bleeding which required noninvasive intervention were in this group. Of the 57 attempts at line insertion, 32 were in the femoral vein, 23 in the internal jugular vein and 2 in the subclavian vein. Image guidance was used in 25 of the 57 attempts. Of the bleeding episodes that required noninvasive intervention, 2 occurred after blind placement of the catheter and 1 was after image guidance was used.Of the 55 patients treated for presumed TTP, 8 died during admission (15%). Mortality in the group of patients receiving platelet transfusion prior to catheter placement was 43% versus 5% in the patients without platelet transfusion beforehand. When adjusted for 4 patients with other causes for their thrombotic microangiopathy, the mortality in the transfused group was 40%. In general, patients receiving platelet transfusion prior to catheter insertion seemed more acutely ill, including 1 patient with HIV and pancreatitis, 1 patient with HIV, and 1 patient with pancreatitis alone. Conclusion:In this single institution retrospective review there were no major bleeding complications associated with plasma exchange catheter insertion in thrombocytopenic patients with presumed TTP. In light of the uncertain risk of platelet transfusion in patients with TTP, it is reasonable to forgo prophylactic platelet transfusion prior to catheter placement. Disclosures:No relevant conflicts of interest to declare.

Assessment of Suny Upstate Medical University's Child Telepsychiatry Consultation Program

The project assesses the child telepsychiatry services provided by SUNY Upstate psychiatrists to several county mental health clinics in central New York State. Data for 45 patients was extracted from pre-consultation forms completed by the referring clinic and postconsultation summaries completed by the Upstate psychiatrists that occurred between July 13, 2009 and May 12, 2010. The study identified characteristics of patients for whom telepsychiatry consultations were sought, why they were sought, and reviewed recommended changes in therapy and medication provided by the telepsychiatry consultant. Analysis of the data showed that there was a large variation in patient characteristics such as age (from age 3 to 17), current living situation, and psychological symptoms. In addition to a family history of mental illness (80%), the most common symptoms were physical aggression (60.0%), defiant/oppositional behavior (57.8%), and attentional problems (55.6%). The most common reason for referral was diagnostic clarification (67%). The child telepsychiatrist recommended a change in medication for most (80.8%) of the patients who were on medications, and to begin medications for most (63.2%) who were not receiving medication at the time of consult. Further, the telepsychiatrist often recommended the addition of family therapy (71.1%) and counseling at school (17.8%). The child telepsychiatric program at Upstate seemed effective. It reached a large variety of children with significant mental disorders. The consultants provided diagnostic clarification and recommended modification of treatment for most. However, this assessment is limited as examined as it did not include follow-up information on whether consultant recommendations were followed and, if they were, whether they were effective.

Psychiatrists Should Be Advocates for Gun-Control Laws

Psychiatrists Should Be Advocates for Gun-Control Laws

A comparison of endometrial and subendometrial vascularity assessed by three-dimensional ultrasonography and power Doppler angiography between healthy fertile women and women with unexplained primary recurrent miscarriage

We compared the characteristics of endometrial-subendometrial vascularity 7 days after ovulation of a natural cycle by transvaginal three-dimensional ultrasonography and power Doppler angiography between 88 patients with unexplained recurrent miscarriage and 46 healthy fertile women. Endometrial vascularization index, flow index, and vascularization flow index, as well as subendometrial vascularization index and vascularization flow index, were reduced significantly in the group with unexplained recurrent miscarriage.

Tuberculous Cervical Lymphadenitis

0196-4399/00 (see frontmatter) © 2010 Elsevier Clinical Microbiology Newsletter 32:19,2010 In 2008, the World Health Organization (1) reported that one-third of the world’s population, or over 2 billion people, are infected withMycobacterium tuberculosis. Most individuals infected with M. tuberculosis have asymptomatic disease, but an estimated 9 million people develop active tuberculosis infections each year resulting in over 2 million deaths. Most cases of tuberculosis are pulmonary in nature, but extrapulmonary infections are not uncommon. Extrapulmonary infections may involve the central nervous and skeletal systems, the kidney, and/or the gastrointestinal tract (2). This case report describes a patient with tuberculous cervical lymphadenitis who presented with no evidence of primary pulmonary infection and a negative tuberculin skin test. This case should serve to remind the reader of the importance of extrapulmonary tuberculous disease in the absence of primary pulmonary infection. Case Report A previously healthy 28-year-old male presented to his primary care physician for evaluation of a mass on the left side of his neck. The neck mass was of sudden onset, and the patient gave no history of febrile episodes, chills, sweats, or sore throat. The patient was employed as a research assistant at a local medical school and, as part of his routine and periodic health assessment, had a tuberculin skin test 5 months previously, which was read as negative. The patient was born in the Philippines, but when he was 6 years old, he moved to the United States with his Mailing Address: Paul A. Granato, Ph.D., Department of Microbiology and Immunology, WH 2204, SUNY Upstate Medical University, 750 East Adams St., Syracuse, NY 13210. Tel.: 315-464-7653. Fax: 315-464-4417. E-mail: granatop@ upstate.edu Case Report

Exploration of a genomic expression and pathway analysis approach to neurocognitive performance: preliminary findings

Exploration of a genomic expression and pathway analysis approach to neurocognitive performance: preliminary findings Chad A Bousman1, Gursharan Chana2, Stephen J Glatt3, Sharon D Chandler1, Todd May1, James Lohr1, Ian P Everall2, William S Kremen1, Ming T Tsuang11Psychiatry, University of California, San Diego, CA, USA; 2Psychiatry, University of Melbourne, Melbourne, Victoria, Australia; 3Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY, USAAbstract: Identification of genomic biomarkers for neurocognitive performance could &shy;revolutionize screening, diagnosis, staging, and/or prognosis practices for HIV-associated neurocognitive disorders (HAND). This study sought to explore the relationship between blood-based gene expression and neurocognitive performance. 8 healthy adults were recruited. Subjects were non-smokers, reported taking no medications, and were free of any psychiatric disorders. Correlations adjusting for education and ancestry were conducted to generate lists of genes significantly correlated with scores on neurocognitive test from the National Institute of Mental Health&rsquo;s Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) consensus cognitive battery (MCCB). Ingenuity pathway analysis was used to identify canonical pathways. For each of the 10 MCCB tests, large effect sizes (r &gt; 0.49) were observed. 65% of the genes and 80% of canonical pathways were unique to 1 of the 10 MCCB tests, albeit none survived a 10% FDR correction. Minimal gene overlap was observed across tests; however, several overlapping canonical pathways were observed. Analysis of the relationship between gene expression alterations and neurocognitive performance may provide the potential for improving our ability to identify genomic markers of HAND as well as provide guidance to physicians and researchers in HIV medicine and other disciplines in their pursuit of viable genomic biomarkers for neurocognitive impairment.Keywords: gene expression, cognitive, methodology, MATRICS

Poster Abstracts from the AAAP 20th Annual Meeting and Symposium

Poster Abstracts from the AAAP 20th Annual Meeting and Symposium

In memoriam Robert B. Barlow, Jr

It is with great sadness that we mark the loss of Dr Robert (Bob) Barlow, a pioneering investigator into the neural basis of visual behavior. Bob had a passion for vision research that was vibrant and engaging. He would surely have remained scientifically active and productive for years to come,

Analgesia and the sonographic Murphyʼs sign

Department of Emergency Medicine, SUNY Upstate Medical University, New York, USA Correspondence to Peter J. Mariani, MD, Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA Tel: +1 315 464 4363; fax: +1 315 464 6229; e-mail: [email protected] Received 8 September 2009 Accepted 19 November 2009

The D&amp;T Report

The D&amp;T Report

A New Milestone in ADHD History: Dr. Gonzalo Rodríguez-Lafora (1917) and the “Unstables”

A New Milestone in ADHD History: Dr. Gonzalo Rodríguez-Lafora (1917) and the “Unstables”José J. Bauermeister and Russell A. BarkleyJosé J. BauermeisterSearch for more papers by this author and Russell A. Barkley1 Retired Professor, Department of Psychology, and Researcher at the Behavioral Sciences Research Institute, University of Puerto Rico. He is an international lecturer, and the author of Hiperactivo, Impulsivo, Distraído ¿ Meconoces?, a parent book for Latino children with ADHD.2 Editor of the ADHD Report, Clinical Professor of Psychiatry at the Medical University of South Carolina (Charleston), and Research Professor of Psychiatry at SUNY Upstate Medical University (Syracuse, NY).Search for more papers by this authorPublished Online:March 2010https://doi.org/10.1521/adhd.2010.18.1.12PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations About"A New Milestone in ADHD History: Dr. Gonzalo Rodríguez-Lafora (1917) and the “Unstables”." , 18(1), pp. 12–13 Previous article Next article FiguresReferencesRelatedDetails Cited byCited by1. The profession of neuropsychology in Spain: results of a national surveyOnline publication date: 9 August 2016. Go to citation Crossref Google Scholar Volume 18Issue 1Feb 2010 Information© 2010 The Guilford PressPDF download

Outpatient Management of Depression, 3rd Edition

Professor of Psychiatry and Lecturer on Bioethics and Humanities at SUNY Upstate Medical University, Syracuse NY and Clinical Professor of Psychiatry at Tufts University School of Medicine, Boston; and Editor-in-Chief of Psychiatric Times. Carolyn B. Robinowitz, MD, Book Editor Marcia L.Verduin, MD, Associate Book Editor

Screening for Genitourinary Abnormalities in Adolescent Males

1. Robert M. Cavanaugh Jr, MD* 1. *Professor of Pediatrics, Director of Adolescent Medicine, SUNY Upstate Medical University, Syracuse, NY After completing this article, readers should be able to: 1. Describe the importance of screening for genitourinary problems in adolescent boys. 2. Delineate the essential components of screening urology in adolescent boys. 3. Explain when and how to perform sexually transmitted infection testing in adolescent boys. 4. Counsel adolescent boys on sexuality-related issues. Pediatricians and other pediatric clinicians are in an ideal position to screen for genitourinary problems in adolescent boys. Much information can be gathered by screening for sexuality-related issues and by investigating specific genitourinary symptoms as they occur. Routine inspection of the genitalia should be considered an essential component of the regular examination for adolescent boys. This article reviews important asymptomatic genitourinary conditions in young men that can be detected in the pediatric office. The routine history for adolescent boys should address reproductive health-care issues, including questions about the dramatic physical changes, intense emotional feelings, and sexual experiences that occur during puberty as well as any specific genitourinary complaints. These and other sensitive issues should be discussed privately with the clinician, unless the patient specifically requests otherwise. Most parents understand the importance of their adolescent having time alone with the examiner and respect his need for privacy. In certain circumstances and in accordance with state laws (see Guttmacher Institute, www.guttmacher.org), confidentiality and treatment of minors younger than 18 years of age may be permitted without parental or legal guardian consent, although open communication always should be encouraged. For an in-depth discussion on confidential health care for adolescents, the reader is referred to the position paper published by The Society for Adolescent Medicine cited in the Suggested Reading list. Clinicians can screen quickly for reproductive health care issues in adolescent boys by asking “trigger” questions (Table 1). General questions regarding pubertal changes are a useful lead into a more detailed sexual history. To …

Seeking Common Ground Between Medical Humanities and Basic Sciences

Letters to the Editor Psychiatry Encompasses Much More Than Clinical Neuroscience To the Editor: We commend the efforts of Reynolds and colleagues 1 to achieve “the reintegration of undergraduate and graduate medical education in psychiatry and neurology under the rubric of clinical neuroscience.” As supervisors and teachers of psychiatry residents, we also agree with those authors that “psychiatry is grounded in clinical neuroscience” and that our residents need a “deeper understanding of genetics, pathophysiology, functional neuroanatomy and neuropsychopharmacology.” However, we believe psychiatry is grounded in much more than clinical neuroscience, and that Reynolds and colleagues have given short shrift to the philosophical, social, psychological, and humanistic foundations of psychiatry. Indeed, though we proceed from different premises than do Healy and Mangin, 2 we agree with their comment that psychiatry “need[s] more, rather than less, philosophy and psychology within the discipline.” One of us (R.P.) has coined the term encephiatrics to encompass a broad-based, pluralistic discipline that incorporates not only the clinical neurosciences but also elements of philosophy, literature, and the world’s spiritual traditions. 3 We do not regard these substantive disciplines as mere elective “frills” in psychiatric education; rather, we believe that residents in psychiatry should be exposed to the humanities and social sciences as an integral and required part of their training. Indeed, the psychiatry residency program at SUNY Upstate Medical University is now developing a “humanities track” for residents who wish to concentrate their studies in this area. We also believe that fostering competency in providing cognitive-behavioral, interpersonal, psychodynamic, and other forms of “talk therapy” must remain a central focus in a resident’s education, so that all aspects of a patient’s illness may be addressed comprehensively and compassionately. In our view, these points were not adequately stressed by Reynolds and colleagues. Ghaemi 4 argued that the pluralism of psychiatrist and philosopher Karl Jaspers “has still failed to be adequately appreciated by the psychiatric profession.” We fully agree. To put it in clinical terms, “The clinician who can instantiate the neurobiology of serotonin in the context of the existential dilemma of the patient . . . has a far better chance of preventing suicide than one who is entrapped in a solitary paradigm.” 5 Ronald Pies, MD Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York, and Tufts University School of Medicine, Boston, Massachusetts; (ronpies@massmed.org). Cynthia M.A. Geppert, MD, PhD, MPH Department of Psychiatry and Religious Studies Program, University of New Mexico, Albuquerque, New Mexico.

Psychiatry Encompasses Much More Than Clinical Neuroscience

To the Editor: We commend the efforts of Reynolds and colleagues1 to achieve “the reintegration of undergraduate and graduate medical education in psychiatry and neurology under the rubric of clinical neuroscience.” As supervisors and teachers of psychiatry residents, we also agree with those authors that “psychiatry is grounded in clinical neuroscience” and that our residents need a “deeper understanding of genetics, pathophysiology, functional neuroanatomy and neuropsychopharmacology.” However, we believe psychiatry is grounded in much more than clinical neuroscience, and that Reynolds and colleagues have given short shrift to the philosophical, social, psychological, and humanistic foundations of psychiatry. Indeed, though we proceed from different premises than do Healy and Mangin,2 we agree with their comment that psychiatry “need[s] more, rather than less, philosophy and psychology within the discipline.” One of us (R.P.) has coined the term encephiatrics to encompass a broad-based, pluralistic discipline that incorporates not only the clinical neurosciences but also elements of philosophy, literature, and the world’s spiritual traditions.3 We do not regard these substantive disciplines as mere elective “frills” in psychiatric education; rather, we believe that residents in psychiatry should be exposed to the humanities and social sciences as an integral and required part of their training. Indeed, the psychiatry residency program at SUNY Upstate Medical University is now developing a “humanities track” for residents who wish to concentrate their studies in this area. We also believe that fostering competency in providing cognitive-behavioral, interpersonal, psychodynamic, and other forms of “talk therapy” must remain a central focus in a resident’s education, so that all aspects of a patient’s illness may be addressed comprehensively and compassionately. In our view, these points were not adequately stressed by Reynolds and colleagues. Ghaemi4 argued that the pluralism of psychiatrist and philosopher Karl Jaspers “has still failed to be adequately appreciated by the psychiatric profession.” We fully agree. To put it in clinical terms, “The clinician who can instantiate the neurobiology of serotonin in the context of the existential dilemma of the patient … has a far better chance of preventing suicide than one who is entrapped in a solitary paradigm.”5 Ronald Pies, MD Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York, and Tufts University School of Medicine, Boston, Massachusetts; ([email protected]). Cynthia M.A. Geppert, MD, PhD, MPH Department of Psychiatry and Religious Studies Program, University of New Mexico, Albuquerque, New Mexico.

Subunit Interactions and Requirements for Inhibition of the Yeast V1-ATPase

Disassembly of the yeast V-ATPase into cytosolic V(1) and membrane V(0) sectors inactivates MgATPase activity of the V(1)-ATPase. This inactivation requires the V(1) H subunit (Parra, K. J., Keenan, K. L., and Kane, P. M. (2000) J. Biol. Chem. 275, 21761-21767), but its mechanism is not fully understood. The H subunit has two domains. Interactions of each domain with V(1) and V(0) subunits were identified by two-hybrid assay. The B subunit of the V(1) catalytic headgroup interacted with the H subunit N-terminal domain (H-NT), and the C-terminal domain (H-CT) interacted with V(1) subunits B, E (peripheral stalk), and D (central stalk), and the cytosolic N-terminal domain of V(0) subunit Vph1p. V(1)-ATPase complexes from yeast expressing H-NT are partially inhibited, exhibiting 26% the MgATPase activity of complexes with no H subunit. The H-CT domain does not copurify with V(1) when expressed in yeast, but the bacterially expressed and purified H-CT domain inhibits MgATPase activity in V(1) lacking H almost as well as the full-length H subunit. Binding of full-length H subunit to V(1) was more stable than binding of either H-NT or H-CT, suggesting that both domains contribute to binding and inhibition. Intact H and H-CT can bind to the expressed N-terminal domain of Vph1p, but this fragment of Vph1p does not bind to V(1) complexes containing subunit H. We propose that upon disassembly, the H subunit undergoes a conformational change that inhibits V(1)-ATPase activity and precludes V(0) interactions.

Lability of Neuronal Lineage Decisions Is Revealed by Acute Exposures to Ethanol

On August 6, 2010, the Editor-in-Chief of Developmental Neuroscience, Steven W. Levison, was contacted by the legal counsel for SUNY Upstate Medical University and informed that an investigative committee at SUNY Upstate had determined that Dr. Michael Miller was guilty of multiple counts of research misconduct, and they requested that Developmental Neuroscience retract the 2009 article authored by Drs. Miller and Huaiyu Hu. The committee did not find Dr. Hu at fault for any scientific misconduct. After independently reviewing the reports of the investigative committee and the rebuttals provided by Dr. Miller, the Editor-in-Chief and the publisher concurred that there were errors in reporting sample sizes and in mathematical calculations. However, at that time it was our view that an erratum was more appropriate than a retraction of the article. Despite the flaws in the analyses of the data, it was our determination that those flaws could be corrected in a published erratum to produce a final product that would be more useful to the scientific community than a complete retraction of the work. On December 10, 2010, we requested that Dr. Miller provide a corrected figure with an explanation of the mistakes that had been previously published. However, that erratum was never published as we were provided with additional information and testimonies that convinced us that the collected data may also be unreliable. Accordingly, on October 18, 2011, we requested that a letter of retraction be provided that was co-authored and co-signed by both authors. It was our view that for an action as severe as an article retraction, both authors needed to sign the retraction letter. However, Drs. Miller and Hu were unable to agree upon a letter that could be jointly signed. Therefore, at the request of the President of SUNY Upstate, with this statement we formally retract the article by Drs. Miller and Hu, Developmental Neuroscience 2009;31:50–57. We have sent correspondence to both authors, to the President of SUNY Upstate and to Dr. Steven Goodman, Vice President for Research at SUNY Upstate, to inform them in advance that this action is being taken by the journal.

Narratives, Normality, and Diagnostic Neutrality

Narratives, Normality, and Diagnostic Neutrality

The SLP and Early Intervention with Infants and Toddlers with Hearing Loss

The SLP and Early Intervention with Infants and Toddlers with Hearing Loss