Transition to Psychiatric Residency: Unique Stresses; Unique Rewards

An individual\u27s decision to pursue a psychiatric residency following medical school training is shaped by many factors. Beginning residents are often ill prepared for the relative impact that the shift from medical doctor to psychiatric resident entails. This paper reviews the literature regarding demographic and psychological factors relating to recruitment, dynamic and practical issues confronting the beginning resident, and various coping styles adopted. These factors are considered in the context of an inpatient setting where the majority of residents begin their training. Much of the resident response is seen as adaptive and a number of strategies for coping are suggested

Positron Emission Tomography in Psychiatry: New Sights, New Insights

Positron Emission Tomography (PET) is a new tool with which to explore the neurobiological basis of psychiatric illness. PET permits in-vivo measurement of regional cerebral blood flow, regional glucose metabolism, as well as information about neurochemicals and their receptors. Since regional cerebral bloodflow and glucose metabolism reflect ongoing neuronal activity, the neural bases of different cognitive processes and emotional states can be discerned using PET. Findings from recent studies in schizophrenia, affective disorders, obsessive-compulsive disorders, anxiety disorders, and dementia are reviewed with a special emphasis on how these findings may\u27 be useful in developing a more comprehensive framework for understanding the neurobiological basis of psychiatric disorders. The relationship between PET and other brain imaging modalities, the imminent improvements in PET technology, as well as future directions of research are discussed

Polymyalgia Rheumatica Presenting as Depression: The Role of the History and Physical Examination in Psychiatric Assessment

Surveys have indicated that physical examination is a diagnostic tool that is infrequently used by psychiatrists. This is an unfortunate state of affairs in light of the act that the bio-psycho-social formulation of health-care problems is integral to the treatment of psychiatric disorders. The situation becomes all the more complex when faced with the high comorbidity of physical and psychiatric illness in the elderly presenting with depression. The physical examination, guided by a detailed history, must be considered an integral part of the assessment of depression in the elderly. A case study of polymyalgia rheumatica presenting as depression is utilized to underscore this imperative

Jim Peter's Collapse in the 1954 Vancouver Empire Games marathon

On 7 August 1954 the world 42km marathon record holder, Jim Peters, collapsed repeatedly during the final 385 metres of the British Empire and Commonwealth Games marathon held in Vancouver, Canada. It has been assumed that Peters’s collapsed from heatstroke because he ran too fast and did not drink during the race held in windless, cloudless conditions with a dry bulb temperature of 28°C. Review of his hospital records recently made available to the authors indicates that Peters may not have suffered from exertional heatstroke, which classically produces a rectal temperature of > 42°C, cerebral effects and a usually fatal outcome without vigorous active cooling. Thermal balance calculations also suggest that the environmental conditions were probably not sufficiently severe to induce heatstroke even at the high rate of energy expenditure sustained by Peters for 2 hours and 22 minutes. Although Peters was unconscious on admission to hospital approximately 60 minutes after he was removed from the race, his rectal temperature was 39.4°C and he recovered fully even though he was managed conservatively and was not actively cooled. We propose that Peters collapse was more likely due to the combination of hyperthermia-induced fatigue which caused him to stop running; the onset of exercise-associated postural hypotension as a result of a low peripheral vascular resistance immediately he stopped running; the combined cerebral effects of hyperthermia, hypertonic hypernatraemia associated with dehydration and perhaps an undiagnosed hypoglycaemia. But none of these conditions should have caused a prolonged period of unconsciousness, raising the possibility that Peters may have been suffering from a transient encephalopathy, the exact nature of which is not currently recognized

Accessing Escalators: A Central Vestibular Disorder After Posterior Fossa Tumor Removal

Abstract About 20% of childhood tumors originate within the central nervous system. Progress in assessment and treatment of these lesions has led to improved survival rates. We describe a patient with a posterior fossa ependymoma who despite a remarkable recovery following treatment has been frustrated by difficulty in using escalators. Such symptom selectivity is explained by specific vertical visuomotor and high-frequency vestibular deficits disrupting the execution of this complex motor act. Escalators are a familiar and convenient means of transport for most city-dwellers. Although stepping on and off a moving staircase soon becomes second nature, it is a complex process requiring integrity of cortical and subcortical structures within the central nervous system. We describe a patient who had resection of a tumor of the fourth ventricle and subsequently experienced difficulty using escalators despite an otherwise almost full neurologic recovery and independence. The neurologic basis of her symptoms is analyzed and presented. Case Study A 31-year-old left-handed lady presented with a 16-year history of difficulty using escalators, particularly in the London Underground. Prior to stepping on the moving steps, she would feel panicky, disoriented, and unconfident at placing her feet. On ascending, she described a sensation of being pulled backward although descent and dismount were less troublesome. Her only other symptoms were difficulty focusing on fast-moving images or credits moving up a television screen, and feeling unsteady when walking on irregular surfaces. She had originally presented at the age of 12 years, following a 2-year history of nausea and vomiting. Investigations revealed a tumor arising from the fourth ventricle and associated hydrocephalus. Apart from mild bilateral papilledema, the neurologic examination was normal. A posterior fossa craniotomy was performed with resection of an ependymoma attached to the floor of the fourth ventricle, followed by a course of radiotherapy. Postoperatively, she had dysconjugate gaze movements, left facial weakness, difficulty feeding, and speech disturbance. Two months later, she developed an obstructive hydrocephalus and a right ventriculoperitoneal shunt was inserted. Over the first postoperative year, the dysphagia resolved and her speech almost returned to normal. Oscillopsia and double vision persisted, with some difficulty writing because of leftsided ataxia. The oscillopsia was treated with clonazepam, the diplopia managed with occlusion of the left eye, and her ataxia improved with regular physiotherapy. Over the subsequent years, she recovered well, finishing and passing a Higher National Diploma course. Eighteen years postoperatively, she demonstrated a vertical pendular and downbeat nystagmus, bilateral horizontal gaze evoked nystagmus, and bilateral internuclear ophthalmoplegia. Vertical optokinetic nystagmus was absent. Head thrust was positive to the right horizontally, and in the vertical plane with head back. Past pointing and disdiadokinesis was note

Resolution of Inflammation Following Treatment of Ankylosing Spondylitis Is Associated with New Bone Formation

ABSTRACT. Objective. To test the hypothesis that in patients with ankylosing spondylitis (AS) a vertebral corner inflammatory lesion (CIL) visible on magnetic resonance imaging (MRI) that completely resolves following treatment with anti-tumor necrosis factor-α (TNF-α) agents is more likely to develop into a de novo syndesmophyte visible on a radiograph as compared to a vertebral corner with no CIL. Methods. Fifty patients with AS, who had MRI at baseline and at followup (mean 19.2 months), and spinal radiography at baseline and after 2 years, were followed prospectively. A persistent CIL was defined as being present on both MRI, while a resolved CIL was defined as present at baseline MRI and completely disappeared at followup MRI. Two readers read the MRI independently, and analyses were done for areas with agreement (concordant reads) and for individual reads. Results. For patients receiving anti-TNF therapy (n = 23), new syndesmophytes developed more frequently from vertebral corners where a CIL had completely resolved on followup MRI (42.9% on concordant reads) as compared to vertebral corners where no CIL was demonstrable on either the baseline or followup MRI (2.4%; p < 0.0001). Results from individual readers showed similar differences. For patients receiving standard treatment (n = 27), the same pattern, although nonsignificant, was observed (20% vs 3.3%; p = 0.16) on concordant reads, as well as on individual reads. Conclusion. Our study of AS spines documents that MRI findings predict new bone formation on radiograph. Demonstration of an increased likelihood of developing new bone following resolution of inflammation after anti-TNF therapy supports the theory that TNF-α acts as a brake on new bone formation. Because the number of new syndesmophytes was low, further study is necessary to make firm conclusions