Wharfedale Hospital

SYSNOPSIS The incidence of past school phobia was surveyed by questionnaire in 786 women under 60 years of age who were members of an agoraphobia correspondence club. Twenty-two per cent admitted to previous school phobia, a proportion similar to that found in 57 non-agoraphobic neurotic controls. Past school phobia predicted an earlier onset of subsequent agoraphobia and a more severe psychiatric state as far as symptoms not specifically agoraphobic were concerned. Adolescent agoraphobic difficulties were more associated with school phobia than with agoraphobia in adult life. It was concluded that school phobia leads to agoraphobia in only a small proportion of cases. Although school phobia may predispose to later agoraphobia, it seems more likely that both conditions reflect a lasting tendency to neurotic illness.

A data set of Attributional Style Questionnaire responses collected by Kaney & Bentall (1989) from persecutory deluded, normal and depressed subjects was added to a similar data set collected by the first author. The attributions made for hypothetical positive and negative events by the combined pool of subjects were then blind rated for internality by five independent judges. Whereas the internality ratings made by the subjects for their own attributions showed evidence of an exaggerated self-serving bias in the case of the deluded subjects, and an absence of such a bias in the case of the depressed subjects, the independent ratings showed no such group differences. These findings suggest that the differences in internality for positive and negative events observed on the ASQ between deluded, normal and depressed subjects may not reflect differences in the types of causal statements made by these subjects but differences in their attributions about their attributions. The relevance of this observation for attribution theory in general and attributional accounts of psychopathology in particular are discussed.

A case of steroid-resistant acquired pure red-cell aplasia associated with a relative and absolute increase of TG cells is described. Removal of T cells enhanced erythroid colony and burst formation in vitro, and it is suggested that TG cells may be implicated in the pathogenesis of this case of acquired pure red-cell aplasia.

INTRODUCTION: Lipohypertrophy (LH) is one of the most common complications of insulin therapy. We conducted a prospective study in 18 UK centres to assess the impact of a targeted LH intervention on a range of clinical, biological and socio-economic parameters. METHODS: Seventy-five insulin-injecting patients were recruited randomly and were followed prospectively for 3-6months, with results compared to baseline values. Interventions included the use of an intensive education program and a switch to a 4mm pen needle. RESULTS: At all injection sites LH decreased significantly by the end of the study, either disappearing completely or shrinking by approximately 50% from its original diameter. Injections into LH decreased by more than 75% by the end. Most patients were not correctly rotating injection sites at the beginning but by the end most were, by a 5-fold margin. Only 1/3 of our subjects used the 4mm needle at the beginning of the study, however, virtually all did by study end. The mean HbA1c improved by more than 4mmol/L and there were significantly lower levels of unexpected hypoglycaemia and glucose variability. Total daily doses of insulin dropped by an average of 5.6 IU by study end. CONCLUSIONS: We believe the impressive clinical improvements seen with training to prevent LH can be achieved by wide adoption of the interventions outlined in this study.

A survey of 870 different adult blood samples (primarily from patients with non-haematological disorders) found that 269 (31%) had increased proportions (> 25%) and/or absolute numbers (> 1.0 x 10(9)/l) of morphologically-defined large granular lymphocytes (LGL), and/or phenotypically-defined NK-associated (NKa) cells. Of these, 112 were re-analysed at least 6 months after initial presentation and were classified as 'persistent' (92/112) or 'transient' (20/112) according to whether or not the original abnormality was still present. Lymphocyte counts in most patients with persistent abnormalities were within normal limits (18/92) or slightly increased (68/92), with only six having a lymphocytosis exceeding 10.0 x 10(9)/l. With the exception of five persistent LGL expansions in which the granular lymphocytes did not express NKa determinants (designated LGL+NKa-), the remaining 87 cases could be phenotypically grouped according to their primary abnormality as CD8+NKa+ (n = 33), CD4+ NKa+ (n = 14), CD8dim+NKa+ (n = 7) or CD8-NKa+ (n = 33). TCR genotypic studies in 58 patients showed that the 16 patients with rearranged TCR components were restricted to the CD8+NKa+ group and that, in most of these, the CD8+ fraction showed abnormal relative CD16/CD56 expression. Persistent neutropenia (n = 15) also appeared to be associated with primary abnormalities of CD8+NKa+ cells (12/15), with 10 of these additionally showing rearranged TCR genes. In contrast, persistently increased CD8dim+NKa+ and CD8-NKa+ components did not appear to phenotypically differ from their corresponding 'counterparts' in normal bloods or in patients with transient LGL/NKa+ abnormalities. This survey has therefore established that persistent LGL/NKa+ abnormalities are considerably more common than suggested in published work, that a high proportion of patients with expanded CD8+NKa+ components, with quite diverse clinical histories, show evidence of clonal lymphoid populations, and that the clonal nature of such disorders appears to be associated with abnormal NKa phenotypic patterns.

This paper reports a study of maternal psychiatric illness in school-phobic adolescents admitted to a psychiatric in-patient unit. These cases have been previously described and studied in various ways (Berg, Nichols and Pritchard, 1969; Berg, 1970; Berg and McGuire, 1971; Berg, Butler and McGuire, 1972; Berg and McGuire, 1974).

The HLA (Human Leucocyte Antigen) types A and B were studied in 80 patients diagnosed as schizophrenic. There was an increased incidence of HLA-BW5 and a decrease in HLA-AW29 and HLA-BW17 as compared with healthy controls. In the sub-group of patients exhibiting Schneider's first-rank symptoms there was an increased incidence of HLA-A1 with a decrease in HLA-A2 and HLA-BW17.

Thirty-six patients with a primary depressive illness, admitted consecutively to hospital, were studied. All patients had a pre-treatment DST, followed by weekly DSTs during a six-week treatment period. Three categories of DST response were identified, on the basis of the serial DSTs. All three groups showed improvement with treatment: the two non-suppressor groups showed normalisation of the DST over the treatment period, but only the normalising nonsuppressors showed a significant correlation between DST normalisation and clinical improvement.

In this study, 42 school phobic youngsters aged 11 to 15 were investigated to find out if they were exceptionally dependent, particularly on their mothers, as had repeatedly been asserted in connection with similar cases, often without adequate supporting evidence of an objective nature (Berg, 1970). The Highlands Dependency Questionnaire (H.D.Q.) was administered to their mothers around the time they were accepted for admission to an adolescent psychiatric in-patient unit. The Questionnaire had previously been found to measure at least two unrelated sorts of dependency, represented by a sociability factor (I) and an immaturity factor (III) with satisfactory reliability and validity; this emerged when a principal component factor analysis was performed on the results of applying it to the mothers of a randomly selected sample of 68 secondary school children from the general population, stratified for age, sex and social class (Berg et al. , 1971). Data on 14 variables was processed on the University of Leeds English Electric KDF9 computer, using a system of standard programmes (Hamilton et al. , 1965). In addition to the two sets of factor scores which were calculated using actual raw score weights, two corresponding sets of subscale scores were calculated using approximate raw score weights; correlations between factor and subscale scores in the control group had been found to be: r = ·87 for sociability and r = ·84 for immaturity (Berg et al. , 1971), whereas in 19 youngsters out of the school phobic group, looked at in another context, they were: r = ·51 for sociability (perhaps explained by a divergence between at least two tendencies which have different emphasis in the factor and subscale scores) and r = ·95 for immaturity. The criteria adopted for the diagnosis of school phobia had been given previously when 29 school phobic cases with similar clinical features were reported in some detail (Berg et al. , 1969).

We describe herpes zoster encephalomyelitis occurring 9 days after the onset of cutaneous zoster in an elderly patient taking low dose weekly methotrexate without concomitant prednisolone.

Abstract A 38-year-old man charged with unlawfully causing grievous bodily Warm to his wife with intent to do her grievous bodily harm pleaded guilty to inflicting grievous bodily harm but denied that there was any intent to cause grievous bodily harm. In his evidence the defendant said that he seemed to be like an observer, he could not influence what he was doing and it was like watching himself hitting himself. Medical evidence called in his defence was to the effect that he was in a state of severe depersonalization and was not able to form a specific intent to cause his wife serious harm. Medical evidence called by the Crown was to the effect that dcpersonalization is a disorder not of doing or volition but of the perception of doing or volition and a depersonalized intent is nevertheless an intent. The defendant was convicted by a majority jury of causing grievous bodily harm with intent to do so. The psychopadiology of depersonalization is discussed and similarities are drawn between this case and cases involving hysterical dissociation where it has been held that the relevant defences are insanity and automatism.

A girl is briefly described who had typical bipolar manic-depressive psychosis starting unusually early at 14 years of age. Symptoms at the time of onset included severe anorexia, school phobia and attempted suicide, about the time of onset. She required unusually high doses of lithium carbonate to obtain adequate plasma levels, and there was a tendency for the administration of antidepressant medication to cause her to switch rapidly from depression to hypomania. The last two findings were shared by her father who also had bipolar manic-depressive psychosis.

This article identifies noise as a factor in disturbing patients' sleep in hospital and discusses the usefulness of earplugs as a method of reducing perceptions of noise and enhancing sleep. A pilot study, comparing the quality and quantity of sleep in patients who used earplugs, with those who did not, showed them to be an acceptable and effective method of facilitating sleep.

It has been found that young people suffering from school phobia, particularly those of secondary school age in Britain, tend to be the youngest in their family (Hersov, 1960; Smith, 1970). This paper reports an investigation carried out in an attempt to confirm and extend this observation. A hundred school-phobic youngsters admitted to Highlands, a psychiatric in-patient unit for adolescents, were looked at from the point of view of order in the sibship; in this respect they were compared with 91 non-school-phobic children suffering from neurotic or conduct disorders admitted to the same hospital unit and with 127 randomly selected normal secondary school children stratified for age, sex and social class. The state of excessive dependency which appears to exist between mothers and their children in school phobia, even in early adolescence (Berg and McGuire, 1971) may be partly due to the circumstance of the affected individual being a younger child in the family.

In order to evaluate a novel technique for measuring haemoglobin A1c using a cassette-based immunoassay method we have undertaken a laboratory evaluation using 48 patient samples and a separate within-clinic prospective study of 59 diabetic patients. Individuals were recruited from general (48 patients), paediatric (19 patients), obstetric (24 patients), and general practice (15 patients) diabetic clinics. Agreement was evaluated between HbA1c results obtained using the new method (AMES DCA 2000) and an established laboratory assay (DIAMAT HPLC system). The mean differences between the two results (AMES DCA 2000-DIAMAT) (95% confidence intervals) were: laboratory -0.69% (-1.42 to 0.04%); paediatric clinic -0.93% (-1.93 to 0.07%); obstetric clinic -0.29% (-1.09 to 0.51%), and general practice clinic -0.77% (-1.3 to -0.24%). For the AMES DCA 2000, the coefficient of variation for HbA1c of 5.2% was 1.6% and for HbA1c of 13%, 2.4%. This instrument was used without difficulty by four different operators. Intra-assay coefficient of variation for each operator was < 3.4%. In 9/18 patients where a specific assessment of clinical utility was made, knowledge of the HbA1c result at the time of consultation lead to a change in treatment. Methodology of this type may be used successfully within a diabetic clinic setting in both primary care and hospital environments.

Click to increase image sizeClick to decrease image sizeKey Words: Health belief modelHealth behaviorDiabetes mellitus Compliance

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Summary A case of severe poisoning with dextropropoxyphene and paracetamol (Distalgesic) in which the cardiotoxic effects of dextropropoxyphene were not reversed by naloxone is reported. A probable reason for this failure is suggested with reference to the differing pharmacological actions of dextropropoxyphene on cardiac conducting tissue and the central nervous system.

This article focuses on the experiences of nurses undertaking nurse independent prescribing in the hospital setting. The challenges and benefits are examined using the reflections of those involved in this initiative.

BACKGROUND: The gastrointestinal tract is a common site of involvement in HIV-infected patients. Gastrointestinal symptoms are common in the general population and are associated with decreased quality of life. METHODS: Ambulatory consecutive HIV-infected patients and consecutive healthy blood donors seen in Jamaica were studied. A 19-item questionnaire of GI symptoms was administered. RESULTS: There were 196 respondents. Among 99 HIV patients, the mean number of symptoms was 2.9 and in 97 controls 3.3 (p=0.091). Dysphagia and odynophagia were present in 8.1% of HIV patients and 3.1% of the controls (p=0.129). Belching was present in 59.6% of HIV patients and in 96.8% of controls (p≤0.001). In the control group, 44.3% had heartburn compared to 29.3% of HIV patients. Within the preceding year, 26.3% of HIV participants and 12.4% of controls sought medical attention for their GI symptoms (p=0.001). GI symptomatology was directly related to immune status in the HIV group as patients with a CD4 count of less than 200 cells/μL reported up to 6 GI symptoms, those with CD4 of 201-350 cells/μL had 3 symptoms, and patients with CD4 greater than 351 cells/μL had 1 symptom. Pain on swallowing, and vomiting were significantly more common in patients with CD4 <350 cells/μL than in controls. CONCLUSIONS: GI symptoms were common in HIV patients and controls. In HIV patients symptoms were directly related to CD4 count. Pain on swallowing and vomiting were significantly more common in patients with CD4 <350 cells/μL than in controls.