Effects of stress and beta 1 blockade on the ventricular depolarization gradient of the rate modulating pacemaker.

Prism-CLR is a closed loop, rate modulating pacemaker that uses ventricular depolarization gradient (Gd) to continuously adjust heart rate. Heart rate response to a formal mental stress protocol, esmolol (500 mcg/kg bolus, 75-125 mcg/kg/min infusion), and mental stress during esmolol infusion were studied in six patients to investigate if Gd and paced heart rate response are under direct beta-adrenergic control. Paced heart rates increased in response to mental stress in a physiological manner (P less than 0.001). Response to esmolol infusion was paradoxical, with increased paced heart rates during esmolol bolus and infusion (P less than 0.05). There was no significant alteration in either systolic or diastolic blood pressure during mental stress or esmolol infusion (P greater than 0.05). Paradoxical increase in paced heart rates during esmolol administration suggests a primary or secondary effect of esmolol to decrease the ventricular depolarization gradient. This hypothesis was supported in four dog studies in which direct Gd measurements were made during esmolol infusion. Mental stress during esmolol infusion resulted in significantly increased paced heart rates (esmolol effect) with blunted changes in heart rate in response to the mental stress. The results of this study suggest that the physiological rate response during mental stress is attributable to sympathetic autonomic response.

Patients who refuse heart transplantation.

Some terminally ill patients refuse proposed heart transplantation. Forty patients were offered this surgery; six (15%) declined. Candidates refusing surgery were likely to have a psychiatric diagnosis and heart disease longer than 1 year. Factors thought to influence the decision to refuse surgery included (1) depression, (2) ambivalence about surgery or survival, (3) previous negative experiences with surgery, (4) acceptance of the inevitability of death, (5) concerns about postoperative quality of life, (6) organic brain syndrome, and (7) denial of the severity of heart disease. Patient refusal of a heart transplant is often disconcerting for members of the transplant team.

Psychiatric distress during stages of the heart transplant protocol.

Psychiatric observations are reported on 101 heart transplant candidates (40 of whom had transplantations). Emotional responses were recorded during the evaluation, during the waiting period, perioperatively, at biopsy, during rejection episodes, and before and after discharge. Those phenomena, with the exception of behavioral management problems, were unrelated to initial psychiatric diagnoses; the diagnoses often reflected emotional reaction to cardiac illness. Most distress after evaluation appeared to be related to the protocol rather than to preexisting psychopathology. The stage of the protocol affected the nature of the reactions. Psychiatric assistance aided the adjustment process.

Initial clinical experience with a rate responsive pacemaker.

Prism-CLR is a new single chamber unipolar pace, bipolar or unipolar sense, rate responsive pacemaker that utilizes a closed-loop system based on the analysis of the evoked potential for rate adjustment. It also has an automatic output regulation feature for capture verification and threshold search. Five patients in whom this pacemaker was implanted exhibited an appropriate rate increase with exercise and psychological stress. Automatic output regulation functioned appropriately in three of five patients. Preliminary data suggest that Prism-ClR is an effective pacemaker for patients who may benefit from rate responsive pacing. The automatic output regulation recognition algorithm may need modification in some patients.

Psychopathology in heart transplant candidates.

Psychodiagnostic data are reported on 69 heart transplant candidates. Twenty-seven patients actually received a transplantation. A high prevalence of anxiety and depression appeared related to their desperate cardiac status. Distressful symptoms did not predict postoperative psychiatric complications. Reduced coping skills as reflected by diagnoses of personality disorders or organic mental impairment were associated with many behavioral problems capable of jeopardizing survival. Psychiatric input is necessary for, and was helpful in, the management of these patients.

The Minnesota Multiphasic Personality Inventory (MMPI) Hysteria (Hy) scale: scoring bodily concern and psychological denial subscales in chronic back pain patients.

Chronic back pain patients were compared to two nonpain comparison groups on Minnesota Multiphasic Personality Inventory (MMPI) Hysteria (Hy) scores and scores on two Hy subscales: Bodily Concern and Psychological Denial. Pain subjects had significantly higher scores on the Bodily Concern Subscale and lower scores on the Psychological Denial Subscale than nonpain subjects with similar elevated Hy scores. However, pain subjects had Psychological Denial scores similar to those of subjects with normal MMPI profiles, despite significantly higher Hy scores. These findings are interpreted to support the hypothesis that, among pain patients, Hy elevations are partially accounted for by the endorsement of a disproportionate number of Bodily Concern items. Finally, within pain patients, scores on the Bodily Concern subscale were significantly related to more indices of pain duration and severity than were scores on the Psychological Denial subscale. The potential clinical utility of scoring these subscales is discussed.

Alcohol use and abuse in college students. II. Social/environmental correlates, methodological issues, and implications for intervention.

This review of alcohol use and abuse in college students presents a summary of the relationships between college student alcohol use and social/environment characteristics. A theoretical integration of the findings of this review with those of Part I of this series supports the prior paper's finding of two patterns of college drinking. This review further suggests that the two types may have differential predictive ability with regard to future problem drinking. Methodological issues in this type of research are reviewed and implications for intervention are considered.

Alcohol use and abuse in college students. I. A review of individual and personality correlates.

This review of alcohol use and abuse in college students presents a summary of the relationships between college student alcohol use and demographic and individual characteristics. A summary of the findings suggests two distinct patterns of alcohol use. For some demographic groups, heavy drinking may be most associated with personal problems, while for others it may be more associated with social and environmental factors. Suggestions for future research of this important issue are presented.

The prediction of chronic pain outcome by psychological variables.

Followup telephone interviews were conducted with fifty-four former patients of a multidisciplinary clinic for the evaluation of chronic pain. Interviews were conducted between thirteen and fifty-five months following initial evaluation at the pain clinic. Followup levels of pain and physical disability were compared with the following measures obtained at initial evaluation: levels of pain and physical disability and scores on the Minnesota Multiphasic Personality Inventory (MMPI), McGill Pain Questionnaire (MPQ), and Zung Depression Inventory (ZDI). In general, both physical disability measures and psychological test scores obtained at initial interview were related to followup measures. However, when the predictive value of initial pain and physical disability was accounted for, psychological test scores tended not to produce further significant increment in predictability. These findings are interpreted to mean that the predictive value of these psychological tests stems less from their reflection of a psychological state or attitude with respect to pain, and more from their tendency to reflect ongoing level of pain, disability, and other pain sequelae. The results support the hypothesis that scores on these psychological tests are, at least in part, a reflection of the actual pain and disability and may not be subject to the same clinical interpretations that scores obtained from a psychiatric sample would be.