Time to consider the role of rationalisation in health psychology.

OBJECTIVE: The objective of this study was to determine the interaction between psychological factors, belief systems, and engagement around public health initiatives. STUDY DESIGN: We conducted a longitudinal observational study, utilising convenience sampling to examine illness-related perception in the immediate and medium-term stages of the first wave of the SARS-CoV-2 pandemic in the UK. METHODS: Weekly questionnaires assessed our primary measure, illness-related perception, using The Health Anxiety Inventory. Other psychological measures included apathy, loneliness, depersonalisation, state anxiety, trait anxiety as well as personality traits. Multiple regressions were performed to determine which psychological factors predicted the variance of health anxiety every week using the enter method. RESULTS: A combination of psychological variables that varied over time and were modulated by external events predicted the evolution of illness-related perception and associated aversion to perceived threat. CONCLUSION: Our findings highlight how in the face of a public health crisis, psychological factors play a determining role in the synthesis of beliefs as well as guiding human behaviour.

Cesarean delivery in a parturient with a left ventricular assist device.

Left ventricular assist devices are implanted pumps designed to treat patients with heart failure, and in some cases, to be a bridge to transplantation for patients who qualify. The preconception presence of a left ventricular assist device is a relative contraindication to pregnancy. Few cases have been published regarding the anesthetic management of parturients with left ventricular assist devices. We present the care of a 24-year-old gravida seven, para two woman who presented for induction of labor at gestational age 34 and 6/7 weeks. Her medical history was significant for the presence of a left ventricular assist device, inserted due to heart failure associated with polysubstance abuse. To our knowledge, this is the first description of successful cesarean delivery under neuraxial anesthesia of a parturient with a left ventricular assist device.

Reduced betweenness centrality of a sensory-motor vestibular network in subclinical agoraphobia.

Agoraphobic patients feel dizzy in crowded open spaces and respond to this symptom with excessive fear and avoidance. These clinical features show great similitude with the newly defined syndrome of persistent postural perceptual dizziness (PPPD). Patients with PPPD show decreased activity and connectivity in regions of the vestibular cortex. Due to the great overlap between these two conditions, we hypothesized that individuals with sub-clinical agoraphobia would show reduction in the connectivity features of these regions. We selected a group of healthy individuals from the Human Connectome Project that self-reported agoraphobia episodes, and compared it with a control group. We accurately matched the two groups for psychological measures and personality traits in order to study the neural correlates of vestibular symptoms independently of possible psychiatric vulnerabilities. We found that the agoraphobia group showed reduced betweenness centrality of a network encompassing key regions of the vestibular cortex. Dysfunctions of the vestibular cortex may explain the dizziness symptom for a disorder previously labelled as psychogenic.

Functional (psychogenic) dizziness.

Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.

Functional and psychiatric vestibular disorders.

Behavioral factors have long been recognized as affecting spatial orientation and balance function. Neuroanatomic and neurophysiologic studies conducted worldwide over the last 30 years have substantially advanced our knowledge about the inherently strong connectivity among threat/anxiety, vestibular, visual, and somatosensory systems in the brain. Clinical investigations have shed greater light on the nature of functional and psychiatric disorders that manifest or magnify vestibular morbidity. Concepts of these syndromes have changed over 150 years. Even their nomenclature has had different meanings in different eras. This chapter will review functional and psychiatric vestibular disorders. Terminology will follow the International Classification of Diseases, 11th edition, beta draft and the International Classification of Vestibular Disorders. Anxiety plays a central role in behavioral vestibular morbidity. Anxiety, traumatic stress, obsessive, and depressive disorders may be primary causes of episodic and chronic vestibular symptoms or secondary complications of other vestibular disorders. These psychiatric illnesses affect 30-50% of patients who consult neurologists or otologists for vestibular symptoms. Coexisting psychiatric disorders adversely affect treatment for patients with structural vestibular diseases, especially when unrecognized. Persistent postural-perceptual dizziness is the leading cause of long-term vestibular disability. Fortunately, pharmacologic, psychotherapeutic, and rehabilitative treatments of these illnesses have improved in recent years.

Discrimination of Aspergillus lentulus from Aspergillus fumigatus by Raman spectroscopy and MALDI-TOF MS.

In 2005, a new sibling species of Aspergillus fumigatus was discovered: Aspergillus lentulus. Both species can cause invasive fungal disease in immune-compromised patients. The species are morphologically very similar. Current techniques for identification are PCR-based or morphology-based. These techniques are labour-intense and not sufficiently discriminatory. Since A. lentulus is less susceptible to several antifungal agents, it is important to correctly identify the causative infectious agent in order to optimize antifungal therapy. In this study we determined whether Raman spectroscopy and/or MALDI-TOF MS were able to differentiate between A. lentulus and A. fumigatus. For 16 isolates of A. lentulus and 16 isolates of A. fumigatus, Raman spectra and peptide profiles were obtained using the Spectracell and MALDI-TOF MS (VITEK MS RUO, bioMérieux) respectively. In order to obtain reliable Raman spectra for A. fumigatus and A. lentulus, the culture medium needed to be adjusted to obtain colourless conidia. Only Raman spectra obtained from colourless conidia were reproducible and correctly identified 25 out of 32 (78 %) of the Aspergillus strains. For VITEK MS RUO, no medium adjustments were necessary. Pigmented conidia resulted in reproducible peptide profiles as well in this case. VITEK MS RUO correctly identified 100 % of the Aspergillus isolates, within a timeframe of approximately 54 h including culture. Of the two techniques studied here, VITEK MS RUO was superior to Raman spectroscopy in the discrimination of A. lentulus from A. fumigatus. VITEK MS RUO seems to be a successful technique in the daily identification of Aspergillus spp. within a limited timeframe.

Isavuconazole activity against Aspergillus lentulus, Neosartorya udagawae, and Cryptococcus gattii, emerging fungal pathogens with reduced azole susceptibility.

Isavuconazole is an extended-spectrum triazole with in vitro activity against a wide variety of fungal pathogens. Clinical isolates of molds Aspergillus lentulus and Neosartorya udagawae and yeast Cryptococcus gattii VGII (implicated in the outbreak in the Pacific Northwest, North America) exhibit reduced susceptibilities to several azoles but higher susceptibilities to isavuconazole.

Polymorphisms in genes encoding nonsarcomeric proteins and their role in the pathogenesis of dilated cardiomyopathy.

Dilated cardiomyopathy (DCM), clinically characterized by contractile dysfunction and ventricular chamber enlargement, is a heterogeneous heart disease leading to progressive systolic heart failure and sudden cardiac death. The etiology of the disease is multifactorial and involves genetic factors, viral infections, autoimmune phenomena, and toxic agents. Within the last two decades, a growing body of evidence has suggested that single-gene mutations play a pivotal role in the development of familial forms of dilated cardiomyopathies. Numerous genes encoding cytoskeletal, sarcomeric, and nuclear proteins have been linked to the pathogenesis of DCM, and most of the respective mutants disrupt the structural integrity of sarcomeres in cardiac myocytes. Frequently, point mutations in cytoskeletal proteins critically diminish force generation and interfere with mechanical transduction within the contractile apparatus of the myocardium, thereby ultimately leading to impaired systolic function. However, hitherto reported sarcomeric gene defects explain the etiology of the disease only in some families, leaving other forms of DCM subentities unresolved. Since one of the major factors in DCM pathogenesis involves autoimmune-mediated damage to cardiac tissue, candidate genes that are involved in controlling immune reactions have currently come into focus in genetic research. We and others have shown that a single-nucleotide polymorphism (SNP) in the gene encoding cytotoxic T-lymphocyte antigen 4 (CTLA4) is associated with the diagnosis of DCM. Cytotoxic T-lymphocyte antigen 4 is an inhibitory receptor molecule expressed on activated T lymphocytes, where it functions as an important negative regulator of T-cell activation by competing with the costimulatory CD28 receptor to bind to B7 receptors localized on the surface of antigen-presenting cells. The observed association between CTLA4 genotypes and DCM suggests that genetic factors contribute to both unbalanced immune responses in the myocardium and the development of left ventricular dysfunction. In this review, we will briefly discuss how these findings may stimulate the search for novel DCM-associated SNPs in human genes expressed in noncardiomyocytes.

Pharmacogenomic testing and outcome among depressed patients in a tertiary care outpatient psychiatric consultation practice.

The authors tested the hypothesis that pharmacogenomic genotype knowledge is associated with better clinical and cost outcomes in depressed patients, after controlling for other factors that might differentiate tested and non-tested patients. Medical records of 251 patients, seen in the Mayo Clinic Rochester outpatient psychiatric practice, who had patient health questionnaire-9 (PHQ-9) scores before and after consultation, were reviewed. Comparisons of differences in pre-consultation and post-consultation depression scores and slopes between tested and non-tested patients and between genotype categories of tested patients, were evaluated, along with healthcare cost and utilization comparisons between tested and non-tested patients, using Kruskal-Wallis tests, Wilcoxon rank-sum tests and group mean comparisons, controlling for significant univariate demographic and clinical differences. Tested patients had significantly higher depression diagnosis frequency, baseline PHQ-9 scores, family history of depression, psychiatric hospitalization history, and higher numbers of antidepressant, mood stabilizer and antipsychotic medication trials. After controlling for these differences, there were no differences between tested and non-tested patients in post-baseline depression scores or slopes for CYP genotype categories. For patients with 5-HTTLPR testing, there was significantly more depression score improvement for patients with the long/long genotype at time 4 (N=55, χ(2)-value=8.0492, P=0.018) and at time 5 (N=44, χ(2)-value=6.1492, P=0.046). For a subgroup (n=46) with ≥two pre- and ≥two post-baseline PHQ-9 scores, the mean difference between pre-baseline and post-baseline PHQ-9 score slopes for tested patients was -0.08 (median -0.01; range -1.20 to 0.15) compared with 0.13 (median 0.02; range -0.18 to 2.16) for non-tested patients (P=0.03). Among genotype categories, mean differences between pre-consultation and post-consultation slopes were significantly better for poor CYP2D6 metabolizers than intermediate or extensive metabolizers (P=0.04); there was a trend for slope differences to be better for 5-HTTLPR long/long genotype patients (P=0.06). Subsets of local tested and consultant-adjusted non-tested controls (n=19), who had 8 years of longitudinal care within the health system, had similar overall mean healthcare costs before and after testing; however, tested patients on average had significantly fewer time-adjusted post-baseline psychiatric admissions (0.8 vs 3.8, P=0.04) and fewer time-adjusted psychiatric consultations and comprehensive mental health-specialty evaluations (4.2 vs 9.9, P=0.03). Prospective study is indicated as to whether and how pharmacogenomic testing in a psychiatric consultation practice may improve clinical and cost outcomes.

Paroxetine for prevention of depressive symptoms induced by interferon-alpha and ribavirin for hepatitis C.

BACKGROUND: Whether antidepressants prevent depression during interferon-alpha/ribavirin treatment for hepatitis C virus infection has yet to be established. AIM: To investigate the use of paroxetine in a prospective, double-blind, placebo-controlled study for this indication. METHODS: Sixty-one hepatitis C virus-infected patients were randomly assigned to the antidepressant, paroxetine (n = 28), or placebo (n = 33), begun 2 weeks before and continued for 24 weeks during interferon-alpha/ribavirin treatment. Primary endpoints included development of major depression and severity of depressive symptoms measured by the Montgomery Asberg Depression Rating Scale (MADRS). RESULTS: Rates of major depression during the study were low (17%) and did not differ between groups. Nevertheless, using published MADRS cut-off scores, the percent of subjects who met criteria for mild, moderate or severe depression during interferon-alpha/ribavirin therapy was significantly lower in paroxetine- vs. placebo-treated subjects (P = 0.02, Fisher's exact test). Assignment to paroxetine was also associated with significantly reduced depressive symptom severity. This effect was largely accounted for by participants with depression scores above the median (MADRS > 3) at baseline in whom paroxetine was associated with a maximal reduction in MADRS scores of 10.3 (95% CI: 2.1-18.5) compared with placebo at 20 weeks (P < 0.01). Study limitations included a small sample size and high drop-out rate. CONCLUSION: This double-blind, placebo-controlled trial provides preliminary data in support of antidepressant pre-treatment in hepatitis C virus patients with elevated depressive symptoms at baseline.

The Basic Symptom Inventory-53 and its use in the management of patients with psychogenic dizziness.

OBJECTIVE: To identify an accurate psychological screening questionnaire to assist in the management of patients with psychogenic dizziness. STUDY DESIGN: Patients referred to the Balance Center of the University of Pennsylvania with a presumptive diagnosis of psychogenic dizziness based on neurotologic assessment were administered a Basic Symptom Inventory-53 (BSI-53) psychological screening questionnaire and were referred for psychiatric assessment. Neither the patients nor the psychiatrist were aware of the results of the BSI-53. The results of the neurotologic assessment, the BSI-53, and the psychiatric assessment were then compared for their degree of association. RESULTS: Strong associations were demonstrated between the results of the BSI-53 questionnaire and the results of the neurotologic and psychiatric assessments. CONCLUSIONS: The BSI-53 is an easily administered, objective, and accurate tool useful in identifying the presence of psychopathology in patients thought to have psychogenic dizziness. It is recommended as a valuable addition to the battery of tests performed when evaluating the dizzy patient.

Neuroimmunologic aspects of sleep and sleep loss.

The complex and intimate interactions between the sleep and immune systems have been the focus of study for several years. Immune factors, particularly the interleukins, regulate sleep and in turn are altered by sleep and sleep deprivation. The sleep-wake cycle likewise regulates normal functioning of the immune system. Although a large number of studies have focused on the relationship between the immune system and sleep, relatively few studies have examined the effects of sleep deprivation on immune parameters. Studies of sleep deprivation's effects are important for several reasons. First, in the 21st century, various societal pressures require humans to work longer and sleep less. Sleep deprivation is becoming an occupational hazard in many industries. Second, to garner a greater understanding of the regulatory effects of sleep on the immune system, one must understand the consequences of sleep deprivation on the immune system. Significant detrimental effects on immune functioning can be seen after a few days of total sleep deprivation or even several days of partial sleep deprivation. Interestingly, not all of the changes in immune physiology that occur as a result of sleep deprivation appear to be negative. Numerous medical disorders involving the immune system are associated with changes in the sleep-wake physiology--either being caused by sleep dysfunction or being exacerbated by sleep disruption. These disorders include infectious diseases, fibromyalgia, cancers, and major depressive disorder. In this article, we will describe the relationships between sleep physiology and the immune system, in states of health and disease. Interspersed will be proposals for future research that may illuminate the clinical relevance of the relationships between sleeping, sleep loss and immune function in humans.

Detection and diagnosis of psychiatric disorders in primary medical care settings.

Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.

A streamlined method for diagnosing common psychiatric disorders in primary care.

Primary care practitioners treat the majority of patients with psychiatric disorders, but many patients in general medical practices continue to suffer from undiagnosed mental illnesses. Over the past 10 years, clinical investigators have focused on enhancing the detection of psychiatric disorders in primary care. Several diagnostic tools have been developed for use by clinicians who are not psychiatrists. However, the time constraints of real-world office practice and the often-cumbersome psychiatric nomenclature have limited their use. Recent studies have tested even more streamlined diagnostic methods that require only a few minutes of physician time while correlating strongly with formal psychiatric evaluations. This article consolidates these research findings with practical experience in the rapid detection of 5 psychiatric conditions commonly encountered in primary care: depression, anxiety, stress reactions, substance abuse, and cognitive impairment. An efficient, 2-step method is described that consists of carefully targeted screening questions followed by a confirmatory evaluation. The screening questions and confirmatory examination can be incorporated easily into most primary care practices.

Heat strain evaluation of chemical protective garments.

BACKGROUND: The purpose of this study was to compare thermoregulatory and subjective responses of 12 test subjects (10 male, 2 female) wearing 5 different Joint Service Lightweight Integrated Suit Technology (JSLIST) prototype and 3 different currently fielded control chemical/ biological (CB) protective overgarments. METHODS: The overgarments were compared while subjects attempted to complete 100 min of moderate exercise (400 W) in an environmental chamber (35 degrees C/50% rh). Rectal temperature (Tre), skin temperature, heart rate, sweating rate, and test time, as well as subjective symptoms of heat illness were measured. Data were analyzed for times earlier than 100 min because subjects were not usually able to complete the 100-min trials. RESULTS: At 50 min, of the 3 controls, the Army/Air Force Battledress Overgarment (BDO) imposed significantly greater heat strain (indicated by Tre 37.90 degrees C) than the Marine Saratoga (SAR) (Tre 37.68 degrees C) and Navy Chemical Protective Overgarment (CPO) (Tre 37.69 degrees C). The JSLIST prototype garments imposed heat strain (50 min Tre 37.73-37.86 degrees C) as well as subjective perception of heat strain, that ranged between the warmest and coolest controls. CONCLUSIONS: In the environmental and exercise test conditions of this study, we did not find the five JSLIST overgarments to be consistently different from one another. Subjects in the control garments were and felt generally warmer (BDO) or cooler (SAR, CPO) than in the JSLIST prototype garments.

Heat strain imposed by toxic agent protective systems.

This study evaluated physiological heat strain from two developmental toxic agent protective systems compared with the standard Toxicological Agent Protective (TAP) suit during exercise-heat stress. Eight subjects (six men, two women) completed three experimental trials, at 38 degrees C, 30% rh, wearing: 1) Self Contained Toxic Environment Protective Outfit (STEPO) with rebreather (STEPO-R); 2) STEPO with tether (STEPO-T) or 3) the standard TAP. The STEPO systems provided effective body cooling of: STEPO-R, 200 +/- 36 W; and STEPO-T, 186 +/- 59 W. TAP had no cooling. All experimental trials used treadmill walking at 0.89 m x s(-1), 0% grade at exercise/rest cycles of 20/10 min for 240 min. Metabolic rates for the treatments were: STEPO-R, 298 +/- 26 W; STEPO-T, 299 +/- 34 W; and TAP, 222 +/- 40 W. Rate of heat storage was less (p < 0.05) in STEPO-R (37 +/- 8 W x m(-2)) and STEPO-T (38 +/- 12 W x m(-2)) than in TAP (77 +/- 15 W x m(-2)). Sweating rate was less (p < 0.05) in STEPO-T (10.0 +/- 4.8 g x min(-1)) than in TAP (23.8 x 11.4 g x min(-1)). There was no difference between STEPO-R (12.3 +/- 5.6 g min(-1)) and the other two uniform systems. Subjects did not complete targeted exposure times of 240 min. Exposure time was longer (p < 0.05) in STEPO-R (83 +/- 22 min) and STEPO-T (106 +/- 39 min) than in TAP (46 +/- 10 min). Predicted time to 39.0 degrees C was less (p < 0.05) in TAP (69 +/- 20 min) than in either STEPO-R (226 +/- 124 min) or STEPO-T (244 +/- 170 min). The results of this study show that cooling in STEPO significantly reduced heat storage relative to TAP. The new generation toxic cleanup uniform systems effectively reduced heat stress and increased work capabilities compared with the standard TAP suit.

Efficacy of venlafaxine in geriatric depression.

Geriatric patients with major depression present clinical challenges not encountered in younger individuals, including a greater incidence of medical comorbidity, higher rates of multiple medication use, changes in drug metabolism due to age or physical illness, and increased sensitivity to antidepressant side effects. Nevertheless, successful treatment of depressive disorders in the elderly improves mental and physical functioning, decreases morbidity and perhaps mortality, and enhances quality of life. Recent research indicates that newer antidepressants are effective for late life depression and safer for older individuals. Among newer antidepressants, venlafaxine has a pharmacological profile that makes it an attractive choice for geriatric patients. It has limited potential to interact with other medications because it only weakly inhibits the cytochrome P450 system and binds to plasma proteins at a low level. Dosing may have to be adjusted for patients with renal failure, but typically not for those with liver disease or other medical conditions. Data from three double-blind and four open clinical trials support the safety and efficacy of venlafaxine for geriatric depression. Patients may experience transient, generally tolerable side effects such as insomnia, nausea, agitation, or dry mouth early in treatment, but more serious problems such as falls or cardiac rhythm disturbances seem to be rare. Treatment emergent hypertension occurs in a small percentage of older patients, generally at doses above 150 mg/day. Finally, emerging data suggest that venlafaxine may be effective for conditions such as stroke, anxiety, and neuropathic pain that frequently accompany depressive disorders in the elderly.

Effects of heart-rate feedback on estimated cardiovascular fitness in patients with panic disorder.

Psychological parameters that are believed to affect estimations of cardiovascular fitness were examined in patients with panic disorder and nonclinical controls. Fifty-four participants [panic disorder patients (n = 27) and age- and sex-matched nonclinical controls (n = 27)] completed a cycle ergometer test and were compared on the basis of estimated VO2 max. Participants were randomly assigned to experimental conditions in which they received heart-rate feedback or no feedback during the test. Patients with panic disorder exhibited lower VO2 max and decreased exercise tolerance (i.e., were more likely to discontinue the test) than nonclinical controls. Furthermore, individuals with high anxiety sensitivity (i.e., a fear of autonomic arousal), but not a panic disorder diagnosis per se, achieved significantly lower VO2 max when provided with heart-rate feedback. Moreover, diagnostic status interacted with levels of anxiety sensitivity to predict VO2 max. Patients with panic disorder display poorer cardiovascular fitness after controlling for anxiety and other factors that underestimate performance during fitness testing.

Diagnosis and treatment of psychologic symptoms and psychiatric disorders in patients with dizziness and imbalance.

Patients with dizziness and psychopathology present diagnostic and therapeutic challenges to clinicians in several specialties. Clinical research is beginning to define the medical-psychiatric interactions that produce many of these patients' symptoms. Treatment research is still in its infancy. A model of illness progression is presented to guide physicians through the evaluation of this patient population. Treatment recommendations are based on current clinical experience.