Repetitive Transcranial Magnetic Stimulation for Major Depressive Disorder in Huntington Disease Patient with Improvement in Neuropsychiatric and Movement Symptoms: A Case Report.

Introduction: Huntington disease (HD) is a progressive disorder characterized by significant neurodegeneration that results in severe neuropsychiatric symptoms and disordered movement. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive treatment that has been used in major depressive disorder (MDD) with great success. Case Presentation: We present a case of a patient with newly diagnosed HD, persistent MDD with suicidal ideation, and generalized anxiety disorder who was treated with rTMS and had sustained significant improvement of her mood disorder with additional improvement of her movement disorder. Conclusion: This result brings into question the use of rTMS to treat MDD and chorea in patients with HD, especially early in its course.

Factors Associated With U.S. Army Physician Service After Obligation Completion.

INTRODUCTION: Approximately, 320 physicians enter active duty in the U.S. Army each year, replacing a similar number separating from service. Despite the significant costs involved in educating and training physicians, factors associated with continued active service after completing obligations have not been well studied. MATERIALS AND METHODS: A retrospective cohort study was conducted of all U.S. Army physicians who graduated medical school in 1987 or later and entered active physician service on or before December 31, 2015. A Cox proportional hazards model was used to evaluate the likelihood of continued service after initial obligations to the Army were satisfied. A logistic regression model examined the likelihood of reaching retirement eligibility for the subgroup entering service before October 1998. RESULTS: Of the 10,490 physicians who met inclusion criteria, 8,009 physicians completed their service obligation by the end of the study. There were 4,524 physicians who entered service before October 1998 and were eligible for the retirement analysis. Several factors were found to be independently associated with a higher likelihood of continued post-obligation service and reaching retirement eligibility. These factors were: years of active service accumulated when obligations were complete; preventive medicine and infectious disease specialization; and male gender. CONCLUSIONS: The physicians most likely to continue serving after completion of their obligation and ultimately retire are those who had the most years of service accumulated when they could leave the Army. Graduates from the Uniformed Services University of the Health Sciences (USU) incur an obligation of 7 years vs. 4 years for most other programs. USU also attracts a higher proportion of applicants with prior military service and pre-medical school service obligations. The lack of significant difference in service after obligation completion or achievement of retirement eligibility between USU and non-USU graduates was explained by the greater total service of USU graduates when their obligations were complete. Changing the obligation and incentives, such as salary, for other accessioning programs to mirror the USU model would likely minimize service differences between USU and non-USU graduates.

Higher Pretreatment Blood Pressure Is Associated With Greater Posttraumatic Stress Disorder Symptom Reduction in Soldiers Treated With Prazosin.

BACKGROUND: In a previously reported positive randomized controlled trial of the α1-adrenoreceptor (α1AR) antagonist prazosin for combat posttraumatic stress disorder (PTSD) in 67 active duty soldiers, baseline symptoms did not predict therapeutic response. If increased brain α1AR activation in PTSD is the target of prazosin treatment action, higher brain α1AR activation should predict greater prazosin efficacy. Although brain α1AR activation is not measurable, coregulated peripheral α1AR activation could provide an estimate of brain α1AR activation. Standing blood pressure (BP) is an accessible biological parameter regulated by norepinephrine activation of α1ARs on peripheral arterioles. METHODS: Effects of baseline standing systolic and other BP parameters on PTSD outcome measures from the previously reported randomized controlled trial were analyzed using linear mixed-effects models. Prazosin participants (n = 32) and placebo participants (n = 35) were analyzed separately. RESULTS: In prazosin participants, each 10-mm Hg higher baseline standing systolic BP increment resulted in an additional 14-point reduction (improvement) of Clinician-Administered PTSD Scale total score at end point (p = .002). All other combinations of baseline BP parameters and PTSD outcome measures were similarly significant or demonstrated trends in the predicted direction. In placebo participants, there was no signal for a baseline BP effect on PTSD outcome measures. CONCLUSIONS: These findings suggest that higher standing BP is a biomarker that helps identify persons with combat PTSD who are likely to benefit from prazosin. These results also are consistent with α1AR activation contributing to PTSD pathophysiology in a subgroup of patients.

A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan.

OBJECTIVE: The authors conducted a 15-week randomized controlled trial of the alpha-1 adrenoreceptor antagonist prazosin for combat trauma nightmares, sleep quality, global function, and overall symptoms in active-duty soldiers with posttraumatic stress disorder (PTSD) returned from combat deployments to Iraq and Afghanistan. METHOD: Sixty-seven soldiers were randomly assigned to treatment with prazosin or placebo for 15 weeks. Drug was titrated based on nightmare response over 6 weeks to a possible maximum dose of 5 mg midmorning and 20 mg at bedtime for men and 2 mg midmorning and 10 mg at bedtime for women. Mean achieved bedtime doses were 15.6 mg of prazosin (SD=6.0) and 18.8 mg of placebo (SD=3.3) for men and 7.0 mg of prazosin (SD=3.5) and 10.0 mg of placebo (SD=0.0) for women. Mean achieved midmorning doses were 4.0 mg of prazosin (SD=1.4) and 4.8 mg of placebo (SD=0.8) for men and 1.7 mg of prazosin (SD=0.5) and 2.0 mg of placebo (SD=0.0) mg for women. Primary outcome measures were the nightmare item of the Clinician-Administered PTSD Scale (CAPS), the Pittsburgh Sleep Quality Index, and the change item of the Clinical Global Impressions Scale anchored to functioning. Secondary outcome measures were the 17-item CAPS, the Hamilton Depression Rating Scale, the Patient Health Questionnaire-9, and the Quality of Life Index. Maintenance psychotropic medications and supportive psychotherapy were held constant. RESULTS: Prazosin was effective for trauma nightmares, sleep quality, global function, CAPS score, and the CAPS hyperarousal symptom cluster. Prazosin was well tolerated, and blood pressure changes did not differ between groups. CONCLUSIONS: Prazosin is effective for combat-related PTSD with trauma nightmares in active-duty soldiers, and benefits are clinically meaningful. Substantial residual symptoms suggest that studies combining prazosin with effective psychotherapies might demonstrate further benefit.

An experimental platform to study the closed-loop performance of brain-machine interfaces.

The non-stationary nature and variability of neuronal signals is a fundamental problem in brain-machine interfacing. We developed a brain-machine interface to assess the robustness of different control-laws applied to a closed-loop image stabilization task. Taking advantage of the well-characterized fly visuomotor pathway we record the electrical activity from an identified, motion-sensitive neuron, H1, to control the yaw rotation of a two-wheeled robot. The robot is equipped with 2 high-speed video cameras providing visual motion input to a fly placed in front of 2 CRT computer monitors. The activity of the H1 neuron indicates the direction and relative speed of the robot's rotation. The neural activity is filtered and fed back into the steering system of the robot by means of proportional and proportional/adaptive control. Our goal is to test and optimize the performance of various control laws under closed-loop conditions for a broader application also in other brain machine interfaces.

Prazosin treatment of trauma nightmares and sleep disturbance in soldiers deployed in Iraq.

Trauma nightmares and sleep disturbance impair combat soldiers' functioning. The alpha-1 adrenoreceptor antagonist prazosin has been demonstrated effective for these symptoms in Vietnam veterans. Thirteen soldiers seeking relief from distressing trauma nightmares impairing military function in northern Iraq in 2006 received prazosin alone or in combination with other psychotropics. Mean prazosin dose was 4.1 (SD = 2.2) mg before bed. Six soldiers improved markedly and 3 moderately on the Clinical Global Impression of Change Ratings of distressing dreams decreased from an average of 7.0 (SD = 0.7) to 2.9 (SD = 3.0, p < .001) and those of disturbed sleep from 6.7 (SD = 0.9) to 3.7 (SD = 2.4, p < .001). Prazosin appears effective and well tolerated in the desert warfare environment.

The long war and parental combat deployment: effects on military children and at-home spouses.

OBJECTIVE: Given the growing number of military service members with families and the multiple combat deployments characterizing current war time duties, the impact of deployments on military children requires clarification. Behavioral and emotional adjustment problems were examined in children (aged 6 through 12) of an active duty Army or Marine Corps parent currently deployed (CD) or recently returned (RR) from Afghanistan or Iraq. METHOD: Children (N = 272) and their at-home civilian (AHC) (N = 163) and/or recently returned active duty (AD) parent (N = 65) were interviewed. Child adjustment outcomes were examined in relation to parental psychological distress and months of combat deployment (of the AD) using mixed effects linear models. RESULTS: Parental distress (AHC and AD) and cumulative length of parental combat-related deployments during the child's lifetime independently predicted increased child depression and externalizing symptoms. Although behavioral adjustment and depression levels were comparable to community norms, anxiety was significantly elevated in children in both deployment groups. In contrast, AHC parental distress was greater in those with a CD (vs. RR) spouse. CONCLUSIONS: Findings indicate that parental combat deployment has a cumulative effect on children that remains even after the deployed parent returns home, and that is predicted by psychological distress of both the AD and AHC parent. Such data may be informative for screening, prevention, and intervention strategies.

Re-entry and reintegration: returning home after combat.

Soldier life exists on a continuum of readiness for deployment. Re-entry and reintegration-the return home and reunion with family and community-key the success of the deployment cycle. In current and projected future operations, the Army and society will both bear the burden of this re-entry and re-integration. Programs and procedures in place work towards improving communication, mitigating distress and resolving crises during reentry and reintegration. Key elements include: inclusion of families and communities early into the planning for reentry and reintegration; normalization (non-medicalization of distress); easy access to behavioral health professionals; and education of families on resources and benefits. Through broad collaboration, maximal benefit to the Soldier, family members and society be realized.