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Vigabatrin, a drug mainly used in the treatment of therapy-resistant epilepsy, has been associated to a large range of adverse effects, including acute psychotic disorders. The authors report the case of a 44-year-old patient with drug-resistant temporal lobe epilepsy that developed an acute psychotic episode about three weeks after initiating medication with vigabatrin. After the withdrawal of vigabatrin and the addition of an antipsychotic drug, the clinical picture improved promptly and the patient was discharged within a short period of time. The authors discuss the patient's diagnosis, the possible mechanisms of vigabatrin-associated psychosis and the therapeutic approach, stressing the questions that concern vigabatrin prescription and withdrawal.

Caregiving and related concepts such as family or caregiver burden have been widely discussed in recent literature. A descriptive, cross-sectional study was conducted in a sample (n = 80) of primary caregivers to severe mental patients (diagnosed schizophrenia, chronic psychosis or affective disorder).To describe the caregivers' and corresponding patients' sample, as well as the nature of existing relationships. Levels of caregiver burden and psychological distress were evaluated and a preliminary analysis conducted on objective and subjective burden correlation.Involvement Evaluation Questionnaire (IEQ), General Health Questionnaire (GHQ) and a semi-structured interview designed for this purpose.The extent of burden was found significant in this sample, being unevenly distributed in its components (e.g. tension, worrying or financial burden). Forty-one percent of caregivers experienced minor psychiatric morbidity. Measures of objective and subjective burden were moderately correlated. The same applied to magnitude of associations between each of them and distress parameters. Higher levels of burden were found in groups of caregivers to more severely ill or disabled patients, while diagnosis was not important for this purpose.Most relatives remain highly involved. These results suggest the need to implement specific interventions addressing psychotic patients as well as their families.

The advances of pharmacological and psychosocial therapies in recent years have deeply changed the perspectives on the treatment of schizophrenia in the community. The hospital-centred models are progressively being replaced with comprehensive community care models. After discussing the main aspects of this evolution at a conceptual level, the authors describe the currently available therapeutic interventions of schizophrenia in the community (pharmacological therapies, psychotherapies, psychosocial and family interventions) and their effectiveness. The authors also discuss the cost-effectiveness studies on the different models of treatment, namely those comparing the community-centred models with the more traditional ones. Finally, the organisational problems of the implementation of community-centred models are discussed and the perspectives in this field in our country are considered.

Periampullary tumors form a clinical entity with common symptoms, similar therapeutic options, unsatisfactory resectability rates and unfavorable prognosis. From April 1970 until March 1994, one hundred and twenty-seven patients with periampullary carcinoma were operated by our surgical team. In 48 of these patients, a resection for cure was performed (38%). Resectability rates varied according to the origin of these tumors, i.e., pancreas-20%, ampulla-76%; distal bile duct-71%, periampullary duodenum-88%. Pancreatic tumors showed a different resectability rate from the other periampullary carcinomas (p = 0.04). Forty-two of these patients had a pancreatoduodenectomy and in the remaining 6 cases a total pancreatectomy was performed. Fifteen patients had major post-operative morbidity (31%) and 8 of these cases died in-hospital (17%). Follow-up data was available in 81% of the patients, survival estimates were calculated according to the Kaplan-Meier method and survival comparisons were made with the Log-rank test. Median survival for resected pancreatic carcinoma was 6 months and for resected tumors of the ampulla 37 months. In this group of patients, pancreatic tumors showed a different survival rate from the remaining periampullary tumors (Log-rank-p = 0.002). This work evidences the need to improve management of periampullary tumors, particularly in-hospital mortality and long-term survival. To achieve these goals, patients with periampullary tumors should be treated in specialized centers and research to improve local and systemic control of this disease should be pursued.

The occurrence of metastases is documented in a varied number of hepato-cellular carcinomas (HCC). The indicative metastasis is very rarely the form of clinical presentation of the disease. Two cases of HCC which were clinically presented in a secondary location, in the bone and skeletal muscle respectively, are described.

Evaluation and quality assurance are primary issues in mental health care today. An up-date of current knowledge and experience in this domain is the main objective of this paper. The authors begin by describing the reasons that justify the current interest in this subject, defining concepts and summarizing the most relevant historical antecedents. This is followed by a discussion of the main methodological aspects--basic concepts (particularly those related to structure, process and outcome), specific issues in mental health service evaluation, difficulties in the implementation of evaluation procedures and choice of indicators. Special attention has been given to the most recent developments in mental health service evaluation--namely those related to assessment needs and quality of life measurement. The impact of the regular use of evaluation instruments on the transformation and development of mental health services is also discussed. The contributions that can be made by evaluation procedures to the definition of mental health policies and to overcome mental health service deficiencies are stressed. Finally, the necessity of joining efforts in order to generalize the use of evaluation and quality assurance instruments in the mental health services in this country is pointed out.

A test was carried out involving 94 newborn babies whose birth occurred in Alfredo da Costa Maternity between November 1991 and February 1994. The aims of this study were to find out the frequency of social and obstetric risks, to assess the neonatal, mobility, namely as regards the withdrawal syndrome, and also the repercussion of drug-addiction in the children's development. The frequency was 1 newborn baby of a drug-addicted mother for 106 pregnant women. In 67 out of 94 cases there was pre-natal follow-up. In such cases, the frequency of prematurity, of the withdrawal syndrome, and the possibility of preventive treatment of sexually contagious illnesses (Syphilis, hepatitis B, and aids) decreased. 8.5% of the 94 newborn babies were handed over to relatives or for adoption. Only in a small number of cases was it possible to keep the babies under regular observation. However, all of them showed hypertony and bulimia, which disappeared between the 8th and 9th months.

1) To determine trends in prevalence of neural tube defects and the impact of therapeutic abortion. 2) To review perinatal management of spina bifida.All spontaneous and therapeutic abortions, still births and live births affected by neural tube defects registered in Alfredo da Costa Maternity in Lisbon, from 1983 to 1992, were retrospectively analysed.Eighty-two cases with neural tube defects are reported and myelomeningocele and anencephaly++ were the most frequent ones. Total prevalence for all defects was 0.78:1000 births with a small upward trend during the last two years. Birth prevalence was 0.6:1000, with a clear downward trend, due to therapeutic abortion. Prenatal diagnosis improved significantly, from 9% of all defects detected in 1983-87 to 77.5% in 1988-92. Since 1989, all cases of anencephaly were detected before birth. Most cases of spina bifida were vaginally delivered, and elective cesarean section occurred in 4. Early closure of the defect was undertaken in 87.6% of the newborns with open spina bifida.While total prevalence of neural tube defects remained stable, with only a small upward trend, prenatal diagnosis and therapeutic abortion resulted in a 56.3% fall in birth prevalence. Optimal management of open spina bifida demands a multidisciplinary team with an individual program for each case.

From January 1980 until October 1991 we operated 112 patients with Gastric cancer in which Surgery was considered palliative by intra-operative criteria or by pathological analysis of the resected specimen. Locally irresectable tumour was found in 24.1% of the cases, peritoneal metastases (mets.) in 21.4%, liver mets. in 17%, lymphatic mets. in 16.1%, and other mets. in 21.4%. Resections were possible in 57 patients (50.8%), with a mortality rate of 10.5%, which was similar to the mortality in the non-resection group (7%) p = 0.2. Median survival for the entire group was 7 months, the non-resection group had a median survival of 4 months, and the resection group of 18 months (p = 6.480 e-0.7). Locally advanced tumors had a better outcome than the metastatic group (p = 0.05), but no difference was observed between patients with liver or peritoneal mets. Patients in stage 3 and 4 of the disease had a different prognosis (p = 0.03), and the resection group within each stage fared better.

Psychiatric morbidity was studied in 73 patients of three Units (Medicine, Surgery and Obstetrics) of a general hospital (S. Francisco Xavier Hospital, Lisbon). In the first stage, the patients were clinically evaluated by their doctors. In the second stage, psychiatrists using the General Health Questionnaire (G.H.Q. 30) interviewed all the patients according to the clinical evaluation, 41% of the patients had a significant psychological disorder. However, very significant differences were found between the prevalence rates in the three units. As defined by the G.H.Q. 30, 50 patients (68.5%) had psychiatric disorders, which is statistically different from the results obtained through clinical evaluation. The depression and anxiety syndromes were the most frequent disorders. Organic mental disorders were less frequent and almost limited to medical patients. The results of this study confirm a high rate of psychiatric morbidity in the general hospital, although considerable differences exist between the three units included in the study. We can also conclude that many psychiatric disorders are not correctly identified. This fact, more frequent in units where there is a more brief doctor-patient relationship, supports the necessity of implementing liaison psychiatry programs.

Miotomy is the most common operation for the treatment of achalasia of the esophagus. The most important complication of this operation is gastro-esophageal reflux, and controversy exists in the choice of a thoracic or abdominal approach to this operation. From 1974 until 1988, our group performed 45 miotomies for achalasia of the esophagus. Follow-up was obtained in 82% of the patients. The thoracic approach was used in 21 cases (tor), and 24 patients were operated through an abdominal approach (abd). All the miotomies had an anti-reflux procedure associated. Post-operative evaluation consisted of: clinical score determination; endoscopy with biopsy; manometry; 24 Phmetry. The clinical score revealed that 47% of the patients in the group tor were asymptomatic, and in the group abd this rate was 53%. Absence of macroscopic esophagitis was registered in 75% of the patients in the group tor, and in 91% in the group abd. Microscopic esophagitis was observed in 42% of the cases in the group tor, and in 45% of the group abd. Manometry revealed a low pressure in the inferior esophageal sphincter in 90% of the cases of the group tor, and in 80% of the group abd. Pathological gastro-esophageal reflux, detected by 24 h Phmetry, was present in 29% of the group tor, and in 36% of the group abd. The results in these two groups were very similar, uniformly favourable, and without evidence of superiority of either operation. The choice of a thoracic, or abdominal approach should depend on associated factors such as patient age, respiratory disease, etc.

In the title compound, C17H27NO4, which is an hydrosinapic acid derivative with increased lipophilicity conferred by an additional alkyl chain, the central and the hexyl linear chains contain slightly shorter bond lengths [C—N = 1.316 (2) Å; average linear chain C—C = 1.487 (6) Å] than reported average values [Csp2—N = 1.334, C—C for CH2—CH2 = 1.524 and 1.513 Å for CH2—CH3]. The 4-hydroxy-3,5-dimethoxyphenyl plane [r.m.s. deviation 0.055 (12) Å] makes an angle of 59.89 (5)° with the central plane of the molecule (composed of the N atom, the carbonyl group and the two methylene C atoms linking the carbonyl group and the ring, [r.m.s. deviation 0.0026 (10) Å], which, in turn, makes an angle of 64.24 (13)° with the essentially planar hexyl chain [r.m.s. deviation 0.035 (18) Å]. The N—H group of the amide group is involved in a bifurcated hydrogen bond towards the hydroxy and one of the methoxy O atoms of the 4-hydroxy-3,5-dimethoxyphenyl substituent of a neighbouring molecule, forming a two-dimensional network in the (100) plane. In addition, the same hydroxy group acts as a donor towards the carbonyl O atom of another neighbouring molecule, forming chains running along the b axis.

In the title compound, C20H26O2, which is the 6-methylene derivative of androstenedione and a synthetic percursor of exemestane, the steroid A ring approximates to a sofa (or envelope) conformation, with the methylene group adjacent to the link to the B ring lying out of the plane of the other atoms. The B and C rings have slightly flattened chair conformations and the D ring is an envelope, with the CH group forming the flap. In the crystal, molecules are linked by two distinct C—H...O hydrogen bonds, involving acidic H atoms close to C=C and C=O double bonds.