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Neuroborreliosis has very low prevalence in Kentucky and coma due to Lyme disease is uncommon in North America. A patient diagnosed with Lyme disease in Kentucky, based on coma, typical inflammatory changes on brain imaging, and a positive ELISA resulted in an erroneous clinical impression. Diagnosis should have been confirmed by a positive result on Western Blot, polymerase chain reaction (PCR), or real-time polymerase chain reaction (RT-PCR) testing. Physicians must apply careful consideration before diagnosing a rare disease in areas where that condition is uncommon without first eliminating other differential options. Neuroborreliosis clinicalfindings are nonspecific and often require confirmatory testing, especially in nonclassical case presentations.

Background: Selection of appropriate pharmacotherapy for psychotic patients who exhibit dangerousness is an important issue. Divalproex is a fast-acting agent which appears to be safe and effective in such circumstances. The objective of the following inpatient study was to investigate divalproex as a pharmaceutical adjunct in treating agitated and/or violent, psychotic schizophrenic subjects., Methods: For the purpose of comparison, 147 hospitalized patients were separated into violent (n = 60) and non-violent (n = 87) groups. In addition to antipsychotic drugs given to all subjects, divalproex was preferentially prescribed for the more dangerous patients (n = 40). The clinical status of demographics and parameters related to dangerousness in all participants was assessed to document differences during these admissions and for rehospitalization over one year., Results: Divalproex was well tolerated; however, one individual developed a transient granulocytopenia. Its use in agitated and/or violent psychotic persons appears to have included a calmer, less dangerous hospital course, like that observed among their less disruptive counterparts., Conclusions: Divalproex seemed to have been helpful in this study at facilitating a more routine hospital course for agitated psychotic patients, similar to that of less overtly disturbed individuals. No significant adverse events were observed. The validity of this study is limited by its retrospective, uncontrolled nature.

Psychosis in general and acute relapse of bipolar illness, in particular, are associated with elevated catecholamine excretion, cardiovascular changes, and changes in intracellular calcium concentration. In an effort to determine if these changes result in observable ECG abnormalities, we retrospectively examined ECG parameters of acutely disturbed bipolar and schizophrenic patients. There were no discrete patterns of abnormalities, and no significant differences were observed between the two patient groups. Most ECG changes in acutely hospitalized bipolar and schizophrenic patients appear to be benign.

Electroconvulsive therapy (ECT) efficacy is related to the stimulus intensity and clinically associated with the duration of the induced seizure. Convulsions lasting 30 to 60 seconds are conventionally considered to be of optimal length, and generally are achieved by applying routine ECT technique. An ictus slightly shorter or longer is usually also therapeutically satisfactory. In our study, seizures lasting between 30 and 60 seconds produced a favorable clinical outcome. A very similar effect was observed in all cases where the duration was within 16 to 120 seconds. However, subjects experiencing intal periods of less than 15 seconds and those over 120 seconds resulted in less favorable response. Detailed records as to medicinal and electrical stimulus doses, seizure timings, etc, were excellent guides for subsequent ECT to achieve appropriate convulsion durations and a safe, satisfactory outcome.

Two hundred and thirty-two black patients (103 men, 129 women) who attempted suicide were referred for psychiatric consultation from January 1976 through August 1987. Black male attempters were (1) more often schizophrenic; (2) more apt to be intoxicated; (3) more commonly psychotic; and (4) more prone to use violent methods. Black women were more likely to manifest clinical depression and much more inclined to choose drug overdose as a method. Women were also more apt to jump from buildings or bridges and deliberately set themselves ablaze. Referrals of suicide attempters increased for both sexes over the study period, and violent methods, particularly firearm use, rose steadily among black women over the 11 1/2 years. Recommendations for providing care to black suicide attempters include (1) appreciation of the psychological effects of racism; (2) increased sensitivity to depressive features in black schizophrenics; (3) consideration of affective disorders in young black males frequently involved in violent acts; and (4) awareness of one's own racially biased attitudes.

Mandatory testing for AIDS is controversial. Such screening has been suggested for prisoners, immigrants, prostitutes, military personnel, and persons contemplating marriage or pregnancy. Quarantining and even tatooing have also been recommended for persons with AIDS. The advent of mass testing raises the issues of (1) proper allocation of scarce AIDS resources; (2) the need for confidentiality of examination reports; (3) the value of this assessment without the existence of a definitive treatment; (4) the possibility of both false positive and false negative results; and (5) the provision of counseling for people with positive testing. Other concerns involve public health needs versus individual rights, and the confidentiality of the doctor-patient relationship. Past epidemics serve as paradigms for the role of mandatory screening and quarantine in a public health crisis. As testing for AIDS is expanded, anticipate that adverse reactions such as panic, depression, grief, compulsive behavior, and suicide attempts will increase. The physician must provide counsel on such matters as "safe sex" practices, avoidance of needle sharing, and early warning signs of AIDS and ARC.