Differences in the diagnosis and management of systemic lupus erythematosus by primary care and specialist providers in the American Indian/Alaska Native population.

Objectives The objective of this study is to investigate differences in the diagnosis and management of systemic lupus erythematosus (SLE) by primary care and specialist physicians in a population-based registry. Methods This study includes individuals from the 2009 Indian Health Service lupus registry population with a diagnosis of SLE documented by either a primary care provider or specialist. SLE classification criteria, laboratory testing, and medication use at any time during the course of disease were determined by medical record abstraction. Results Of the 320 individuals with a diagnosis of SLE, 249 had the diagnosis documented by a specialist, with 71 documented by primary care. Individuals with a specialist diagnosis of SLE were more likely to have medical record documentation of meeting criteria for SLE by all criteria sets (American College of Rheumatology, 79% vs 22%; Boston Weighted, 82% vs 32%; and Systemic Lupus International Collaborating Clinics, 83% vs 35%; p < 0.001 for all comparisons). In addition, specialist diagnosis was associated with documentation of ever having been tested for anti-double-stranded DNA antibody and complement 3 and complement 4 ( p < 0.001). Documentation of ever receiving hydroxychloroquine was also more common with specialist diagnosis (86% vs 64%, p < 0.001). Conclusions Within the population studied, specialist diagnosis of SLE was associated with a higher likelihood of having SLE classification criteria documented, being tested for biomarkers of disease, and ever receiving treatment with hydroxychloroquine. These data support efforts both to increase specialist access for patients with suspected SLE and to provide lupus education to primary care providers.

Pupil size regulation of threshold of light-induced melatonin suppression.

The capacity of pupil dilation to affect light-induced plasma melatonin suppression was tested by exposing human subjects with freely constricting or pharmacologically dilated pupils to either 50 (n = 6), 100 (n = 8), or 200 lux (n = 5) of white light presented over the entire visual field. Pupil dilation significantly enhanced low level white light-induced melatonin suppression over that elicited with freely constricting pupils. Although 100 and 200 lux white light exposures resulted in significant melatonin suppression over control (no light) conditions, the effects of 50 lux were not strong enough to demonstrate statistically significant suppression with six subjects. Linear regression did not reveal a systematic relationship between theoretical retinal illuminance in Trolands and magnitude of melatonin suppression. These results suggest that pupil diameter may be a factor in the effectiveness of light stimuli used to shift circadian rhythms or to treat seasonal depression or sleep disorders.

Triazolam diminishes daytime sleepiness and sleep fragmentation in patients with periodic leg movements in sleep.

Fifteen subjects (9 men and 6 women) exhibiting objective evidence of excessive daytime somnolence and periodic leg movements in sleep underwent 4-7 days of treatment with triazolam (0.25 or 0.50 mg) and placebo in a double-blind crossover design. One night of polysomnography followed by daytime multiple sleep latency testing were conducted on the first and last days of each treatment block. By the last day of treatment, the mean multiple sleep latency test score after triazolam (9.0 minutes) was significantly greater than that after placebo (5.7 minutes). Thus, triazolam treatment led to a decrease in daytime somnolence. Triazolam also improved sleep architecture and continuity; it increased total sleep time, decreased the number of awakenings and arousals, and decreased stage 1 and increased stage 2 percentages. Although the frequency of periodic electromyographic bursts remained unchanged, the frequency of associated arousals decreased after treatment. Short-term treatment with triazolam is thus effective in diminishing daytime sleepiness and in improving sleep architecture, continuity and duration in patients with periodic leg movements in sleep. These effects do not seem to be mediated through a decrease in periodic leg movement activity.

Effects of green or white light for treatment of seasonal depression.

Twelve subjects with winter depression were treated with equal quanta of green or white light in a randomized crossover study. Each treatment condition consisted of 2 hours of exposure each morning for 1 week, with at least 1 interventing week without treatment. Ratings made without knowledge of treatment condition were done before and after each condition. Both treatments significantly reduced depression ratings. White light was significantly more effective than green light in reducing endogenous symptoms, but not the "atypical" symptoms that are common features of winter depression. Furthermore, sequence of treatment conditions influenced antidepressant responses. Broad-band white light may be optimal for maximizing therapeutic response.

2- versus 4-hour evening phototherapy of seasonal affective disorder.

Seasonal affective disorder (SAD) has been successfully treated with bright light, and morning exposure has been deemed more effective than exposure at other times. Evening treatment may offer a practical advantage, but the optimal duration of exposure has not been established. Six SAD patients were treated at home for 1 week with 2500 lux of light given either from 6 p.m. to 8 p.m. or from 6 p.m. to 10 p.m. using a counterbalanced crossover design with a minimal withdrawal period of 1 week between conditions. Both treatments were effective in reversing SAD symptoms, but neither treatment was superior. These results suggest that evening phototherapy for as little as 2 hours may be a useful and reasonable alternative for the treatment of SAD.

Light-induced plasma melatonin suppression in seasonal affective disorder.

1. Subjects with seasonal affective disorder were exposed to 0, 500 and 1000 lux of white light for one hour beginning at 0300 hours. 2. Plasma samples were taken periodically and analysed for melatonin. 3. Plasma melatonin levels were suppressed by exposure to both 500 and 1000 lux light levels, suggesting that SAD patients show no neuroendocrine insensitivity to light but may show supersensitive responses to light.

Treatment of winter depression with a portable, head-mounted phototherapy device.

1. A portable, head-mounted device was developed for administration of light therapy. A randomized crossover protocol was used to test the therapeutic efficacy of this device, compared to a standard light box, for treatment of winter depression. 2. Depressive symptoms were significantly reduced by both the head-mounted device and the light box. 3. Therapeutic efficacy of the two devices was not significantly different. 4. The head-mounted device was rated by patients as significantly more convenient than the conventional light box; this may be important in improving patient compliance.

Ontogeny of conditioned heart rate to an olfactory stimulus.

When heart rate is used as the index of conditioning, rat pups younger than 15 days of age do not display an odor-shock association. This constitutes a marked delay relative to the development of a somatomotor conditioned response. The incapacity to display autonomic learning to an olfactory stimulus prior to day 15 is not due to the inability to perceive and to orient to the olfactory stimuli used, nor to the inability to make unconditioned phasic cardiac changes. Rather, the late development of the heart rate conditioned response may indicate that the central neural mechanisms mediating heart rate conditioning are distinct from, and mature later than those mediating 1) heart rate orienting and 2) somatomotor conditioning. Evidence from studies in adult species is used to support these speculations.

Rate of aging and dietary restriction: sensory and motor function in the Fischer 344 rat.

Sensory and motor task performance was assessed at 3 to 4 month intervals in chronically underfed and ad libitum-fed control rats from maturity into senescence. Diet-restricted rats weighed less than controls and lived significantly longer. Diminished body mass improved the underfed rats' abilities to hang suspended from a wire, to maintain balance on a narrow beam, and to descend from a wire mesh pole in a coordinated fashion. Underfed rats, however, lost these abilities at the same rate as did control rats. Undernutrition did not affect the startle response to acoustic stimulation, nor did it influence auditory or visual lead stimulus inhibition of the startle response. Both groups of animals showed progressive, age-related losses of sensory-motor function which proceeded at the same rate in each group. Life-prolonging undernutrition did not appear to retard aging of these simple, reflexive behaviors.

Animal models of infantile amnesia, benign senescent forgetfulness, and senile dementia.

The Jacksonian principle of hierarchical development and dissolution of function was applied to infantile amnesia and memory loss in senescence. When the Jacksonian model is generalized to include life-span changes in memory it predicts a last-in, first-out appearance and disappearance of memory processes. Those memory capacities that are the last to appear in ontogeny should be the first to be compromised in aging. To evaluate this proposition in a specific context, the rodent literature on long-term memory in infant, adult, and aged animals was surveyed. Three types of memorial processes that emerged sequentially in development were identified and then examined in adult and aged rats. Although strong support of the Jacksonian principle did not emerge from this analysis, the data were sufficiently positive to suggest that the theory was still viable and even vigorous enough to guide future research on both the normal and pathological processes of development and aging.