The relationship between objective parameters of sleep and measures of fatigue, depression, and cognition in multiple sclerosis.

BACKGROUND: People with multiple sclerosis (MS) often report poor sleep, fatigue, sleepiness, depression and cognitive dysfunction. Interrelationships between symptoms and sleep are poorly understood. OBJECTIVES: To document objective parameters of sleep measured by polysomnography (PSG) and multi-sleep latency tests (MSLTs) in patients experiencing fatigue or sleepiness and to determine whether they correlate with symptoms. METHODS: Thirty-two MS patients, not on therapy, with fatigue or sleepiness completed the Modified Fatigue Impact Scale, Fatigue Severity Scale, Epworth Sleepiness Scale, Beck Depression Index and NeuroTrax cognitive tests and underwent PSG and MSLTs. RESULTS: Sleep efficiency (SE) averaged 75.1%. wake after sleep onset (WASO), sleep onset latency and multi-sleep latency were 66.2, 43.4 and 10.43 min, respectively. Stage N3 and rapid eye movement sleep were absent in 10 and four patients, respectively. Increased limb movements were observed in eight patients. Obstructive sleep apnea was observed in 12 patients. Neither SE nor WASO correlated with fatigue or sleepiness. SE correlated with the global cognitive score and with executive function and information processing subscales. CONCLUSIONS: Overall, 30/32 MS patients reporting fatigue or sleepiness had evidence of one or more sleep disturbances. PSG should be considered in MS patients reporting fatigue or sleepiness in order to rule out treatable disturbances.

Longitudinal MRI study of hippocampal volume in trauma survivors with PTSD.

OBJECTIVE: The authors prospectively explored whether a reduction in the volume of the hippocampus occurs in recent trauma survivors who develop posttraumatic stress disorder (PTSD). METHOD: Thirty-seven survivors of traumatic events were assessed within a week of the traumatic event and 6 months later. The assessment included magnetic resonance imaging of the brain (including 124 coronal slices of 1.5-mm thickness), psychometric testing, and structured clinical interviews. The Clinician-Administered PTSD Scale conferred PTSD diagnoses at 6 months. RESULTS: Ten subjects (27%) had PTSD at 6 months. The subjects with PTSD did not differ from those without PTSD in hippocampal volume (right or left) at 1 week or 6 months. There was no reduction in hippocampal volume in the PTSD subjects between 1 week and 6 months. CONCLUSIONS: Smaller hippocampal volume is not a necessary risk factor for developing PTSD and does not occur within 6 months of expressing the disorder. This brain abnormality might occur in individuals with chronic or complicated PTSD.

Dimension reduction and source identification for multispecies groundwater contamination.

Assessment of chemical contamination at large industrial complexes with long and sometimes unknown histories of operation represents a challenging environmental problem. The spatial and temporal complexity of the contaminant may be due to changes in production processes, differences in the chemical transport, and the physical heterogeneity of the soil and aquifer materials. Traditional mapping techniques are of limited value for sites where dozens of chemicals with diverse transport characteristics may be scattered over large spatial areas without documentation of disposal histories. In this context, a site with a long and largely undocumented disposal history of shallow groundwater contamination is examined using principal component analysis (PCA). The dominant chemical groups and chemical "modes" at the site were identified. PCA results indicate that five primary and three transition chemical groups can be identified in the space of the first three eigenvectors of the correlation matrix, which account for 61% of the total variance of the data. These groups represent a significant reduction in the dimension of the original data (116 chemicals). It is shown that each group represents a class of chemicals with similar chemo-dynamic properties and/or environmental response. Finally, the groups are mapped back onto the site map to infer delineation of contaminant source areas for each class of compounds. The approach serves as a preliminary step in subsurface characterization, and a data reduction strategy for source identification, subsurface modeling and remediation planning.

Successful treatment of feline pancreatitis using an endoscopically placed gastrojejunostomy tube.

A cat with pancreatitis, diagnosed using abdominal ultrasonography, fine-needle aspirate cytopathology, and increased concentration of serum trypsin-like immunoreactive substance, was treated successfully using jejunal alimentation provided through a percutaneous gastrojejunostomy tube. This method of jejunal feeding is less technically difficult, less stressful for the patient, and has fewer complications than surgically placed jejunostomy tubes. Nutritional support with jejunal feeding is superior to total parenteral nutrition, as it maintains gut integrity, decreases septic complications, and may reduce exogenous insulin requirements. The methods of tube insertion and maintenance, and the physiological advantages over other feeding methods are described.

Auditory startle response in trauma survivors with posttraumatic stress disorder: a prospective study.

OBJECTIVE: Previous studies have shown elevated autonomic responses to startling tones in trauma survivors with chronic posttraumatic stress disorder (PTSD). The origin of these abnormal responses is obscure. The present study attempted to clarify this issue by prospectively evaluating responses to sudden, loud tones in individuals who arrived at a hospital emergency room after psychologically traumatic events. METHOD: By using a previously established protocol, autonomic and muscular responses to the tones were evaluated at 1 week, 1 month, and 4 months after the traumatic event. Structured diagnostic interviews performed at 4 months classified subjects into groups with (N=36) and without (N=182) PTSD, which were further subdivided according to the presence or absence of major depressive disorder as follows: neither PTSD nor depression (N=166), depression alone (N=16), PTSD alone (N=21), and both PTSD and depression (N=15). RESULTS: The groups showed comparable physiological responses to the tones at 1 week posttrauma. However, at 1 and 4 months posttrauma, the subjects with PTSD showed a greater heart rate response and required more stimulus trials to reach the criteria of skin conductance and orbicularis oculi electromyogram nonresponse. These findings were not significantly influenced by comorbid depression and were not explained by the severity of the traumatic event or by the intensity of the initial symptoms. CONCLUSIONS: Differences in physiological response to startling tones develop along with PTSD in the months that follow a traumatic event. This pattern supports the theories that associate PTSD with progressive neuronal sensitization.

Predictors of chronic post-traumatic stress disorder. A prospective study.

BACKGROUND: Most individuals who, shortly after trauma, express symptoms of post-traumatic stress disorder (PTSD) recover within one year of their traumatic experiences. In contrast, those who remain ill for one year rarely recover completely. The early identification of the latter is, therefore, very important. AIMS: To prospectively evaluate predictors of PTSD at four months and one year. METHOD: We followed 236 trauma survivors recruited from admissions to a general hospital's emergency room for four months, at which point 41 (17.4%) met diagnostic criteria for PTSD. Twenty-three of these individuals, and 39 individuals without PTSD at four months, were assessed again at one year. RESULTS: Depressive symptoms were the best predictors of PTSD at both time points. Intrusive symptoms and peri-traumatic dissociation were better at predicting four-month PTSD than one-year PTSD. CONCLUSIONS: The occurrence of depression during the months that follow a traumatic event is an important mediator of chronicity in PTSD.

A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder.

BACKGROUND: Physiological arousal during traumatic events may trigger the neurobiological processes that lead to posttraumatic stress disorder (PTSD). This study prospectively examined the relationship between heart rate and blood pressure recorded immediately following a traumatic event and the subsequent development of PTSD. METHODS: Eighty-six trauma survivors who presented at the emergency department of a general hospital were followed up for 4 months. Heart rate and blood pressure were recorded on arrival at the emergency department. Heart rate, anxiety, depression, and PTSD symptoms were assessed 1 week, 1 month, and 4 months later. The clinician-administered PTSD scale defined PTSD status at 4 months. RESULTS: twenty subjects (23%) met PTSD diagnostic criteria at the 4-month assessment (PTSD group), and 66 (77%) did not (non-PTSD group). Subjects who developed PTSD had higher heart rates at the emergency department (95.5+/-13.9 vs 83.3+/-10.9 beats per minute, t=4.4, P<.001) and 1 week later (77.8+/-11.9 vs 72.0+/-9.5 beats per minute, t=2.25, P<.03), but not after 1 and 4 months. The groups did not differ in initial blood pressure measurement. Repeated-measures analysis of variance (ANOVA) for heart rate showed a significant group effect (P<.02), time effect (P<.001), and group x time interaction (P<.001). The time effect and group x time interaction remained significant when adjusted for sex, age, trauma severity, immediate response, and dissociation during the traumatic event. CONCLUSION: Elevated heart rate shortly after trauma is associated with the later development of PTSD.

Prospective study of posttraumatic stress disorder and depression following trauma.

OBJECTIVE: The purpose of this study was to prospectively evaluate the onset, overlap, and course of posttraumatic stress disorder (PTSD) and major depression following traumatic events. METHOD: The occurrence of PTSD and major depression and the intensity of related symptoms were assessed in 211 trauma survivors recruited from a general hospital's emergency room. Psychometrics and structured clinical interview (the Structured Clinical Interview for DSM-III-R and the Clinician-Administered PTSD Scale) were administered 1 week, 1 month, and 4 months after the traumatic event. Heart rate was assessed upon arrival at the emergency room for subjects with physical injury. Twenty-three subjects with PTSD and 35 matched comparison subjects were followed for 1 year. RESULTS: Major depression and PTSD occurred early on after trauma; patients with these diagnoses had similar recovery rates: 63 survivors (29.9%) met criteria for PTSD at 1 month, and 37 (17.5%) had PTSD at 4 months. Forty subjects (19.0%) met criteria for major depression at 1 month, and 30 (14.2%) had major depression at 4 months. Comorbid depression occurred in 44.5% of PTSD patients at 1 month and in 43.2% at 4 months. Comorbidity was associated with greater symptom severity and lower levels of functioning. Survivors with PTSD had higher heart rate levels at the emergency room and reported more intrusive symptoms, exaggerated startle, and peritraumatic dissociation than those with major depression. Prior depression was associated with a higher prevalence of major depression and with more reported symptoms. CONCLUSIONS: Major depression and PTSD are independent sequelae of traumatic events, have similar prognoses, and interact to increase distress and dysfunction. Both should be targeted by early treatment interventions and by neurobiological research.

Predicting PTSD in trauma survivors: prospective evaluation of self-report and clinician-administered instruments.

BACKGROUND: This study examined the ability of commonly used questionnaires and a structured clinical interview to predict PTSD in recent trauma survivors. METHOD: Horowitz's Impact of Event Scale (IES), Speilberger's State Anxiety (SANX) and the Peri Traumatic Dissociation Questionnaire (PDEQ) were administered one week post-trauma to 239 traumatised individuals recruited from a general hospital emergency room. The IES, the SANX, the civilian version of the Mississippi Scale for Combat Related PTSD (MISS), and the Clinician Administered PTSD Scale (CAPS) were administered one month and four months post-trauma. Receiver operator characteristic (ROC) analysis was used with these data. RESULTS: All questionnaires were better than chance at predicting PTSD. The so-called PTSD questionnaires (IES and MISS) were not better than the more general ones. No difference in predictive value was found when questionnaires were carried out one week or one month after a trauma. Recovery was better predicted than PTSD, and the CAPS was better than the questionnaires. DISCUSSION: The use of psychometrics and clinical interviews to predict PTSD should be guided by clinical relevance and by the availability of resources.

Treatment of recent trauma survivors with benzodiazepines: a prospective study.

BACKGROUND: Most types of psychotropic drugs have been tried in the treatment of chronic posttraumatic stress disorder (PTSD), but have yielded limited results. Theory and retrospective research predict that early treatment may be more efficacious. Specifically, high-potency benzodiazepines have been recommended for the treatment of acute responses to trauma and for prevention of PTSD. This study prospectively evaluates the effect of early administration of benzodiazepines on the course of PTSD and PTSD symptoms. METHOD: Thirteen trauma survivors (the benzodiazepine group) were treated within 6.7 +/- 5.8 days after the trauma (range, 2-18) with either clonazepam (N = 10, 2.7 +/- 0.8 mg/day) or alprazolam (N = 3, 2.5 mg/day). Thirteen other trauma survivors, pair-matched with subjects in the active treatment group for gender and symptom severity in the first week after the trauma, constitute the control group. Both groups were reevaluated 1 and 6 months after the trauma for PTSD symptoms (Horowitz Impact of Event Scale; Mississippi Rating Scale for Combat-Related PTSD-civilian trauma version), PTSD status (Clinician Administered PTSD Scale), state anxiety, depression, and resting heart rate. RESULTS: Subjects in the benzodiazepine group did not differ from controls in 1-month and 6-month PTSD and anxiety scores. Repeated measures ANOVA showed no group or group-by-time effect on psychometric measures. A trend toward group-by-time interaction in resting heart rate was noted (progressive decrease in the benzodiazepine group). Nine benzodiazepine subjects and 3 controls met PTSD diagnostic criteria 6 months after the trauma. CONCLUSION: Contrary to expectations, the early administration of benzodiazepines to trauma survivors with high levels of initial distress did not have a salient beneficial effect on the course of their illness, while reducing physiologic expression of arousal.

RDA and RDH retention surveys. CDA's Council on Education and Professional Relations.

This article presents the results of a survey of dental auxiliaries conducted by the California Dental Association's Council on Education and Professional Relations. The survey found that a surprisingly high number of dental assistants (56 percent) and hygienists (42 percent) are considering whether to remain in the dental health care field, stated reasons for this include lack of paid benefits and little opportunity for career growth. The results also suggest, however, that if the perceived deficiencies in these areas were addressed, RDAs and RDHs might remain in the profession.

A comparison of opinions from parents of disabled and non-disabled children on behavior management techniques used in dentistry.

The purposes of this study were to compare the acceptance of pediatric dental behavioral management techniques by 40 parents of children with disabilities with that of 40 parents whose children were not disabled and to determine the effect of prior information on the level of acceptance for both groups of parents. An instrument containing a demographic questionnaire and using a visual analog scale asked parents to indicate acceptance level of hand-over mouth, sedation, restraint using Papoose board, and general anesthesia for either a check-up/cleaning, dental filling, or treatment of a toothache. One half of each parent group received a written description and rationale for the behavior management technique prior to rating acceptance, and the other half did not. Although differences were found between parents of the disabled and non-disabled and between those informed and not informed, only one technique and procedure (restraint for check-up/cleaning) was significantly different for acceptability (p < or = 0.05), and that was between uninformed parents of non-disabled children and informed parents of disabled children. We conclude that having a disabled child or receiving a prior rational for pediatric behavior management techniques was not significantly related to differences in acceptance of the techniques for the procedures described.

Sensitivity and specificity of death certificate diagnoses for dementing illnesses, 1988-1990.

OBJECTIVE: To evaluate the extent to which mortality data, which is often used to track secular trends for specific diseases, underestimates the prevalence of dementia. DESIGN: Retrospective analysis of existing data. SETTING: Department of Mental Health inpatient facilities in South Carolina. SUBJECTS: Inpatients at Department of Mental Health facilities who were listed in the South Carolina Statewide Alzheimer's Disease and Related Disorders Registry and who died between 1988 and 1990 (n = 450). MAIN OUTCOME MEASURES: Sensitivity and specificity of dementia diagnoses on death certificates compared to medical record diagnoses for inpatients with a pre-mortem dementia diagnosis. RESULTS: Twenty-three percent of death certificates contained any dementia diagnosis (104/450). The sensitivity of death certificates varied by type of dementia (28 percent for Alzheimer's disease; 8 percent for multi-infarct dementia) as well as by race, sex, and age. CONCLUSIONS: Mortality statistics substantially underestimate the prevalence of dementing illnesses and do not fully represent the public health burden of dementia.

A report on dementia in South Carolina, 1988-1990.

With the over age 65 population growing at a faster rate than the under 65 population, and with the strong effect of age on the incidence and prevalence of dementia, South Carolina faces a major health problem among its elderly residents by the year 2010. This report summarizes data on the 4,283 persons identified by the Statewide Alzheimer's Disease and Related Disorders Registry during the period 1988 to 1990. Sixty-one percent of these cases had a diagnosis of Alzheimer's disease or senile dementia and 62 percent of these were currently institutionalized. The demographic distribution of the AD cases did not change over the three-year period. Compared to community cases, those in institutions were generally older, and more likely to be women, unmarried, and white. The average time from onset of symptoms to diagnosis of AD was about five years.

Distribution of major dementias by race and sex in South Carolina.

Preliminary data from the newly implemented Registry for dementing illnesses was used to examine the distribution of four types of dementia in black and white residents of South Carolina. The data for 1464 subjects were abstracted by field research nurses in state mental health facilities. Overall, 649 patients (44.3%) were black and 765 (52.3%) were white. Women comprised 53.8% of all cases of dementia in this study. The overall distribution included 66% Alzheimer's disease (AD), 12% multi-infarct dementia (MID), 10% alcoholic dementia (ALC), nine percent other-medical and three percent other-unspecified. Though the proportion of blacks does not exceed one-third of the total population of S.C., blacks comprised 44.3% of all cases of dementia. AD accounted for 79% of all cases of dementia in women, but only 51% of such cases in demented men, who showed an apparent preoponderance of MID and alcoholic dementia. The frequency distribution of MID was equal in blacks and whites. Educational level had no discernible effects. Though not directly comparable, these preliminary findings are similar to those of the Copiah County Study, including a higher frequency of AD with advancing age.

The need for an Alzheimer's disease patient registry in South Carolina.

There has been considerable interest in establishing a statewide registry of Alzheimer's disease patients. The need for such a registry, how it could be effectively organized, and the potential benefits from such a registry are discussed. The current status of the South Carolina Registry for Dementing Illnesses is reported.

Extrapulmonary silicosis: a clinical, morphologic, and ultrastructural study.

A variety of silicotic lesions derived from thoracic silicosis via lymphohematogenous spread to the liver, spleen, bone marrow, and extrathoracic lymph nodes are described. The morphologic features of these lesions depend on the extent of macrophage aggregation, the occurrence of fibrogenesis, and the development of necrosis and degradative changes in macrophages and adjacent extracellular matrix, presumably caused by lysosomal enzymes released from macrophages. Ultrastructurally, the degenerative alterations of matrix material include longitudinal splitting and breakage of collagen fibrils into segments one and three quarters the length of the original fibrils and deposition of flocculent electron-dense material either focally or diffusely around collagen fibrils. The corresponding changes viewed light microscopically are those of fibrinoid necrosis. The sclerohyaline nodule, the characteristic lesion of silicosis, includes all of these features as it evolves through nodular histiocytic and subsequent fibrohistiocytic phases. Its ultimate morphology appears to be determined by the reassembly of the degraded matrix into non-native, fibrous long-spacing collagen via a spiny collagen intermediary. The sclerohyaline nodule occurs infrequently in the spleen and liver, although less typical lesions caused by silica alone or admixed with other dusts seem to occur more commonly in these organs. These lesions appeared as loose or nodular histiocytic or fibrohistiocytic aggregates. Nonspecific fibrous nodules or more extensive fibrosis, as seen in portal triads, may represent advanced stages of such lesions. Acute or healed focal segmental glomerulonephritis occurred in 40 per cent of the cases, suggesting that it may be an important remote effect of silicosis. Continuous destruction of lymphocytes adjacent to silicotic nodules may be an antigenic source of the high concentration of autoimmune reactants described in silicosis.

Retinoic acid binding protein in human and experimental pancreatic carcinomas in hamsters.

Cytoplasmic retinoic acid binding protein (cRABP) is present in human fetal pancreas and becomes nondetectable in the normal adult pancreas. The binding protein for retinoic acid becomes apparent again in pancreatic cancer. Similar fluctuations in the content of cRABP occur in the hamster. The binding protein is undetectable in the normal adult hamster pancreas, while it was detected in several transplantable adenocarcinomas in the Syrian golden hamster.

Retinoic acid binding protein in normal and neopolastic rat prostate.

Sucrose density gradient analysis of cytosol from normal and neoplastic rat prostatic tissues exhibited a peak of (3H) retinoic acid binding in the 2S region, corresponding to the cytoplasmic retinoic acid binding protein (cRABP). In the Fisher-Copenhagen F1 rat, cRABP was present in the lateral lobe, but could not be detected in the ventral nor in the dorsal prostatic lobes. Four sublines of the R-3327 rat prostatic tumor contained similar levels of this binding protein. The absence of cRABP in the normal tissue of origin of the R-3327 tumor, the rat dorsal prostate, and reappearance in the neoplastic tissues follows a pattern described in other human and animal tumors. The occurrence of cRABP in the well-differentiated as well as in the anaplastic R-3327 tumors in which markers which reflect a state of differentiation and hormonal regulation, such as androgen receptor, 5 alpha reductase, and secretory acid phosphatase are either markedly reduced or absent, points to cRABP as a marker of malignant transformation.