Use of the hospital anxiety and depression scale as a screening tool for patients with headache

BACKGROUND

The Hospital Anxiety and Depression Scale (HADS) is becoming widely used in medical settings to screen for anxiety or depressive disorders. It has been shown to be a good screening instrument in different ethnic and disease populations. The objective of this study was to evaluate the validity and reliability of HADS in patients with headache at a headache clinic.

METHODS

Consecutive new patients to a headache clinic at the Taipei Veterans General Hospital from September to December, 1998, were recruited in the study. The participants completed the HADS questionnaire and underwent a psychiatric semistructured interview according to the Diagnostic and Statistical Manual (4th revision). The reliability and validity of the HADS were evaluated with respect to headache.

RESULTS

A total of 62 patients (21 men, 41 women) completed the study. The HADS had a good internal consistency when applied to patients suffering from headache, with a Cronbach's alpha coefficient of 0.84 and a split-half reliability of 0.84. Factor analysis in this sample revealed four factors: anxiety, depression, panic and somatic factors. A total of 48 patients (77%) had a psychiatric diagnosis. The frequency of depressive disorders was 57% and anxiety disorders 31%. A total HADS score of 10 or more was the optimal cut-off point for depressive disorders. The sensitivity was 85.7%, and the specificity 33.3%. A total score of at least 13 was the optimal cut-off point for anxiety disorder. The sensitivity was 84.2%, while the specificity was 41.9%.

CONCLUSIONS

Depression and anxiety were quite common among patients with headache in a headache clinic. The HADS can be used as a screening instrument for depressive and anxiety disorders. Because of the low specificity, the HADS should not be used solely as an indicator of psychiatric comorbidity among patients with headache in a headache clinic. This is the first study that verifies the use of the HADS as a psychiatric screening tool in patients with headache by comparing the scores of the HADS with psychiatric diagnoses.

Rhenium-188-Labeled DTPA: a new radiopharmaceutical for intravascular radiation therapy

Balloon angioplasty is a standard treatment for artherosclerotic coronary artery disease. However, its clinical value is reduced by a high restenosis rate. A new concept in preventing restenosis is the use of a liquid-filled balloon containing a beta-emitting radioisotope. In this study, we performed biodistribution studies of Re-188 perrhenate and Re-188 diethylenetriaminopentaacetate (DTPA) to assess the resulting organ dose values in the event of balloon rupture if these agents are used for the clinical inhibition of restenosis after percutaneous transluminal coronary angioplasty (PTCA). After injecting Re-188 preparations intravenously, rats were killed at 10 min, 30 min, 60 min, 2 h, and 6 h (n = 5 per group). Tissue concentrations were calculated and expressed as percent injected dose per gram or per milliliter (%ID/g or %ID/mL). In addition, urine excretion and thyroid gland uptake were evaluated in rats (n = 5 per group) with a gamma camera after administration of 37 MBq (1 mCi) of each agent. Our data showed that both agents were excreted primarily via urine. However, the excretion of Re-188 DTPA was much faster than that of Re-188 perrhenate via the urinary system. The biodistribution data revealed that radioactivity levels in the stomach and the thyroid gland were high in the perrhenate group but low in the Re-188 DTPA group. The concentration levels in other tissues including lung, liver, testis, muscle, and blood were low throughout this study for both agents. The thyroid radiation value in the Re-188 perrhenate group was 0.163 mGy/MBq, which was much higher than that of the Re-188 DTPA group (0.0167 mGy/MBq). The stomach radiation value was as high as 0.127 mGy/MBq for Re-188 perrhenate, compared with 0.013 mGy/MBq for Re-188 DTPA. In conclusion, in the event of balloon rupture, the release of Re-188 DTPA results in lower radiation doses than Re-188 perrhenate, especially to the thyroid gland and the stomach. Our data suggest that Re-188 DTPA is a useful radiopharmaceutical for endovascular irradiation.

Helicobacter pylori infection and gastric emptying in cirrhotic patients with symptoms of dyspepsia

BACKGROUND/AIMS

Chronic gastric Helicobacter pylori infection is common in patients with dyspeptic symptoms. The effect of H. pylori infection on gastric emptying, in cirrhotic patients with dyspeptic symptoms, has never been studied. Therefore, we investigated the incidence of H. pylori infection and its relationship with gastric emptying in cirrhotic patients with dyspepsia.

METHODOLOGY

A solid-phase gastric emptying study and 14C urea breath test were performed in 80 cirrhotic patients with dyspepsia. The severity of cirrhosis was assessed according to Child-Pugh's classification.

RESULTS

The overall incidence of delayed gastric emptying was 75%. Delayed gastric emptying incidences according to severity of cirrhosis were 71.4% for Child-A, 73.1% for Child-B, and 80.8% for Child-C. The differences were not significant. The incidence of H. pylori infection was 52.5% overall. H. pylori infection rates were 46.4% for Child-A, 42.3% for Child-B, and 69.2% for Child-C. Although there was a tendency for the infection rate to increase with the severity of liver cirrhosis, the difference was not significant. In addition, there were no significant differences in the incidences of H. pylori infection among patients with normal and delayed gastric emptying.

CONCLUSIONS

Delayed gastric emptying is common in cirrhotic patients with dyspepsia. However, the status of H. pylori infection does not seem to play a role in delayed gastric emptying in these patients.

Chondroid tumors of the larynx: computed tomography findings

PURPOSE

Chondromas and chondrosarcomas of the larynx are rare cartilaginous tumors making up less than 1% of all laryngeal tumors. Patients typically present with symptoms of hoarseness, dysphagia, or dyspnea. The most common location in the larynx for these tumors is the cricoid cartilage. Radiographically, these lesions are typically hypodense, well-circumscribed masses containing mottled calcifications with smooth walls centered within the cartilage.

MATERIALS AND METHODS

We present 6 cases of chondroid tumors of the larynx.

RESULTS

One patient had a chondroma, 4 patients had low-grade chondrosarcomas, and 1 patient had an intermediate-grade chondrosarcoma. Two partial laryngeal resections and 4 total laryngectomies were performed.

CONCLUSIONS

In most cases of chondroma or chondrosarcoma of the larynx, conservative surgery should be attempted, but total laryngectomy may be required for large or recurrent lesions.

Impact of dairy farming on well water nitrate level and soil content of phosphorus and potassium

The Cornell Teaching and Research Dairy Farm was used to study the historical influence of dairy farming on water quality and soil chemical properties. The farm has milked approximately 360 cows for the past 20 yr and is situated on 526 ha of cropland (390 ha utilized for dairy production) near Harford, New York. Mass nutrient balances (N, P, K) were constructed with historical data from 1979 and 1994 for the 390 ha used for dairy production. The amount of imported N increased more than 40% from 1979 to 1994, although there were year-to-year variations, depending on crop yields. Although nutrient balance (imported minus exported nutrients) as a percentage of imported nutrients on the farm remained relatively unchanged during this period, balance of N increased from 43.1 metric tonnes in 1979 to 66.0 metric tonnes in 1994. However, P and K remained about the same because of the reduced use of fertilizers in the 1990s. During the 15-yr period, total milk production increased more than 40% (2502 to 3604 metric tonnes from 1979 to 1994). Analysis of well water suggested that increasing amount of N balance on the farm resulted in increased well NO3-N concentration. The mean of five wells located in the corn fields increased from 3.3 to 7.0 mg/kg in NO3-N concentration, 70% of the EPA upper limit. Soil P increased from 6.0 to 24.0 (kg/ha) during the same period. Soil K did not change. Mass nutrient balances are important in determining the amount of nutrients remaining on farm. This study suggests N, P, and K balance can be used as an indicator of potential for increased NO3-N concentrations in wells and soil P and K levels, respectively.

ApoE genotype in relation to AD and cholesterol: a study of 2,326 Chinese adults

OBJECTIVE

To calculate the frequencies of apolipoprotein E (apoE) alleles in a large Chinese community sample and to compare the serum cholesterol levels of epsilon2, epsilon3, and epsilon4 carriers.

BACKGROUND

In comparison with Western populations, a lower frequency of the apoE epsilon4 allele among the Chinese has been proposed as one factor for the lower prevalence of AD found in Chinese populations, but there are insufficient Chinese data on epsilon4 frequency that are based on large community samples. In addition, although Western studies have repeatedly found a lower cholesterol level in epsilon2 carriers and a higher cholesterol level in epsilon4 carriers in comparison with epsilon3 homozygotes, two Chinese studies have yielded inconsistent findings between them.

METHODS

During the incidence phase of an epidemiologic survey of several neurologic disorders in a Chinese community, the authors took blood samples from 2,326 participants to determine the apoE genotypes and to measure cholesterol levels.

RESULTS

The allelic frequencies of epsilon2, epsilon3, and epsilon4 were 11.8%, 76.4%, and 11.8% among 17 AD patients, and 7.8%, 84.1%, and 8.1% for the entire sample. The mean cholesterol level of the epsilon2 carriers was significantly lower, and that of the epsilon4 carriers significantly higher, than that of the epsilon3 homozygotes.

CONCLUSIONS

The obtained epsilon4 rate of 8.1% is lower than most of the Western findings, and this may account in part for the lower prevalence of AD found among the Chinese. The associations between the apoE genotype and serum cholesterol level are similar between Chinese and white populations.

Colour doppler imaging for diagnosis of intracranial hypotension

BACKGROUND

Measurement of CSF pressure is the only known way to confirm the diagnosis of intracranial hypotension. We aimed to assess colour doppler flow imaging (CDFI) for measurement of blood flow of the superior ophthalmic vein for the diagnosis of intracranial hypotension.

METHODS

We enrolled 25 consecutive patients with orthostatic headache who had clinical features of intracranial hypotension. We defined low-pressure headache as cerebrospinal-fluid pressure below 60 mm H2O. We used CDFI to measure the diameter and maximum flow velocity of the superior ophthalmic vein in all patients. Magnetic resonance imaging of the brain and lumbar puncture with measurement of cerebrospinal-fluid pressure within 24 h were also done after sonographic examination. The control group comprised 13 healthy individuals of a similar age; in addition, those patients who had orthostatic headache without low pressure served as a control group for the patients.

FINDINGS

Of the 25 patients recruited for this study, 13 satisfied the criteria for low-pressure headache. The remaining 12 patients with normal cerebrospinal-fluid pressure had transformed migraine (five patients) or chronic tension-type headache (seven patients), and therefore served as the control group for the patients. The mean diameter of the superior ophthalmic vein was substantially larger in the patients with intracranial hypotension (3.9 [SD 0.2] mm) than in the healthy controls (2.6 [0.4] mm) and the controls from the patients' group (2.7 [0.2] mm) (p<0.0001). The mean maximum flow velocity was significantly higher in the intracranial-hypotension group (17.0 [SD 3.4] cm/s) than in the healthy controls (7.9 [1.1] cm/s) and the other patients (7.3 [1.7] cm/s) (p<0.0001). Seven patients with intracranial hypotension were reassessed after treatment with epidural blood patch. After this treatment the clinical symptoms were relieved and there was a striking reversal of the superior ophthalmic vein flow.

INTERPRETATION

CDFI to measure blood flow of the superior ophthalmic vein provides a practical, simple, and non-invasive diagnostic method for suspected intracranial hypotension.

Modification of sample size in group sequential clinical trials

In group sequential clinical trials, sample size reestimation can be a complicated issue when it allows for change of sample size to be influenced by an observed sample path. Our simulation studies show that increasing sample size based on an interim estimate of the treatment difference can substantially inflate the probability of type I error in most practical situations. A new group sequential test procedure is developed by modifying the weights used in the traditional repeated significance two-sample mean test. The new test has the type I error probability preserved at the target level and can provide a substantial gain in power with the increase of sample size. Generalization of the new procedure is discussed.

Human liver-specific very-long-chain acyl-coenzyme A synthetase: cDNA cloning and characterization of a second enzymatically active protein

Activation of fatty acids, catalyzed by acyl-coenzyme A (acyl-CoA) synthetases, is required for their subsequent metabolism. Peroxisomes and microsomes contain very-long-chain acyl-CoA synthetases (VLCSs) capable of activating fatty acids with a chain length of 22 or more carbons. Decreased peroxisomal VLCS activity is, in part, responsible for the biochemical pathology in X-linked adrenoleukodystrophy (X-ALD), illustrating the importance of VLCSs in cellular fatty acid homeostasis. We previously cloned two human genes encoding proteins homologous to rat peroxisomal VLCS; one (hVLCS) is the human ortholog to the rat VLCS gene and another (hVLCS-H1) encodes a related heart-specific protein. Here, we report the cloning of a third gene (hVLCS-H2) and characterization of its protein product. The hVLCS-H2 gene is located on human chromosome 19 and encodes a 690-amino-acid protein. The amino acid sequence of hVLCS-H2 is 44-45% identical and 67-69% similar to those of both hVLCS and hVLCS-H1. COS-1 cells transiently overexpressing hVLCS-H2 activated the very-long-chain fatty acid lignocerate (C24:0) at a rate >1.5-fold higher than that of nontransfected cells (P < 0.002). The hVLCS-H2-dependent activation of long- and branched-chain fatty acids following transient transfection was less striking. However, hVLCS-H2-dependent acyl-CoA synthetase activity with long- and very-long-chain fatty acid substrates was detected in COS-1 cells stably expressing hVLCS-H2. For all substrates tested (C18:0, C20:0, C24:0, C26:0), the hVLCS-H2 catalyzed activity was significantly increased (P < 0.01 to P < 0.0001). By both Northern analysis and reverse transcription polymerase chain reaction, hVLCS-H2 is expressed primarily in liver. Indirect immunofluorescence of COS-1 cells or human hepatoma-derived HepG2 cells expressing epitope-tagged hVLCS-H2 revealed that the protein was associated with the endoplasmic reticulum but not with peroxisomes. Thus, the primary role of hVLCS-H2 is likely to be in fatty acid elongation or complex lipid synthesis rather than in degradation.

A double-blind, placebo-controlled study of tacrine in Chinese patients with Alzheimer's disease

The purpose of the study was to evaluate the efficacy and safety of tacrine over 30 weeks in Chinese patients with probable Alzheimer's disease (AD). A total of 100 patients with mild to moderate AD were recruited and randomly assigned to active or placebo treatment. The active group received 30 mg/day of tacrine for the first 6 weeks, 60 mg/day for the next 6 weeks, 90 mg/day for 6 more weeks and then 120 mg/day for the remaining 12 weeks. Safety evaluations included biweekly determinations of alanine aminotransferase (ALT). The primary outcome measures were Cognitive Abilities Screening Instrument (CASI), Clinical Global Impression of Change (CGIC) by investigator and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Secondary outcome measures were Mini-mental State Examination (MMSE), Alzheimer's Deficit Scale (ADS) and CGIC by caregivers. Sixty-eight patients were included in an intent-to-treat analysis (48 active and 20 placebo); 56 patients had evaluable data at week 30 (36 active and 20 placebo). The results of the complete case analysis revealed a significant improvement in the CASI and MMSE scores of the active group in the 18th week (90 mg/day) and the 30th week (120 mg/day) (p < 0.01). In the intent-to-treat analysis, significant improvement of the active group was noted on CASI at week 30 (p = 0.05), but there was no significant difference in the measures of IQCODE, CGIC and ADS. The primary reasons for withdrawal of tacrine-treated patients (39 patients, 52%) were asymptomatic ALT elevation, anorexia and nausea/vomiting. These patients all recovered from the adverse events on discontinuation of treatment. Tacrine produced a statistically significant improvement in the CASI and MMSE in Chinese patients with mild to moderate AD using a lower dose than in western people.

Predictors of depression among Chinese family caregivers of Alzheimer patients

From April 1996 to January 1997, 74 Alzheimer disease (AD) patients and their caregivers were recruited for participation in a comprehensive assessment at the Veterans General Hospital-Taipei, a 2,198-bed tertiary care teaching hospital in Taipei, Taiwan. Diagnosis of AD was made according to criteria of the Diagnostic and Statistical Manual of Mental Disorders-III-R (DSM-III-R). All AD patients were tested with the Chinese version of Cognitive Abilities Screening Instrument (CASI). Their primary caregivers rated the patients using the Revised Memory and Behavior Problems Checklist (RMBPC), the short version of Geriatric Depression Scale (GDS-S), and obtained information about coping strategies using the Carer's Stress scale. The three subscale scores for memory-related problems, depression, and disruptive behavior were obtained from the RMBPC. Scores for three subscales for management of situations, meaning, and distress were obtained from the coping strategies' assessment. Depression was defined as a GDS-S score > or = 5. Among the 74 AD patients, 38 were men and 36 women. Their ages ranged from 47 to 90 years, with a mean age of 72.2 years (SD, 9.0). The CASI scores ranged from 1 to 88 (mean, 45.2; SD, 22.9). Thirty-three caregivers were men and 41 were women. Their age ranged from 20 to 85 years, with a mean age of 53.5 years (SD, 16.9). Twenty-six of the 74 caregivers (35.1%) were classified as depressed. The GDS-S scores of caregivers were correlated positively with the frequency of the use of a management of distress coping strategy and the frequency of the patients' disruptive behavior and were correlated negatively with the educational years of the caregivers.

Gastric emptying rate assessment based on the proportion of intra-abdominal radioactivity in the stomach

Using scintigraphic techniques, the rate of gastric emptying is calculated by quantifying the absolute radioactivity within a gastric region of interest (intragastric method) with the time of meal completion considered 100% retention. However, this technique has significant limitations arising from subject movement and radionuclide gamma-ray attenuation, which may render curve fitting difficult, particularly in patients with gastroparesis. In an attempt to minimize these limitations, we have expressed the intragastric content as a percentage of the total abdominal radioactivity (abdominal method) and compared these two methods.

METHODS

Forty-five subjects in a sitting position consumed a meal consisting of two fried eggs labeled with 99mTc, two slices of toast and 300 mL 5% glucose water (412 kcal). Data were acquired at a rate of one frame every 5 min from the left anterior oblique view. Using the two methods, the intragastric retention ratios at 30, 60, 90, 120 and 240 min and the 50% emptying time (T50) were obtained from both observation and calculation by power exponential fit. R2, representing goodness of fit of the nonlinear curve fitting, was calculated.

RESULTS

There were no differences in the calculated values of T50 between the two methods. Quantitative estimates of T50 by extrapolation of a power exponential fit were feasible in 42 of the 45 subjects when the abdominal method was used, compared with only 29 of the 45 subjects when the intragastric method was used. In the 23 subjects with delayed emptying, quantitative estimates of T50 were feasible in 20 subjects when the abdominal method was used, compared with 7 subjects when the intragastric method was used. Using the abdominal method as opposed to the intragastric method also significantly improved R2. The difference between observed values and estimated values of T50 and intragastric retention ratios at 30, 90 and 120 min was smaller using the abdominal method.

CONCLUSION

Scintigraphic measurement of gastric emptying calculated using the proportion of the abdominal radioactivity in the stomach offers substantial advantages over conventional methods, particularly in patients with gastroparesis.

Primary iliac muscle abscess due to Staphylococcus aureus

A 55-year-old man presented with a 3-day history of lower back pain and right thigh pain. A diagnosis of discogenic pain had been made at two other hospitals. He had been admitted to a medical center for acute hepatitis 5 months prior to this admission. Large doses of parenteral hydrocortisone were used for 13 days to treat acute hepatitis. At the present admission, he was unable to stand and refused to move his right leg. There was mild tenderness in the right lower abdomen on deep palpation. Passive flexion and rotation of the right hip produced mild pain, while passive extension of the right hip produced severe pain and resistance. The Patrick test was positive and the psoas sign was present on the right side. The erythrocyte sedimentation rate (ESR) was 66/hr. The C-reactive protein (CRP) level was 0.161 g/L. Abdominal sonography showed a lobulated mass in the right iliac fossa. Magnetic resonance imaging showed severe swelling of the right iliac muscle with a central heterogeneous mass. Debridement, drainage of the abscess, and application of a septopal chain were performed via an anterior retroperitoneal approach, and parenteral cephazolin and gentamicin were administered. A culture of the abscess grew Staphylococcus aureus. The ESR and CRP concentrations decreased to within the normal ranges 3 weeks later. Awareness of this disease entity, careful physical examination, and appropriate imaging studies such as ultrasonography and magnetic resonance imaging are key to making a correct diagnosis.

Open bedside tracheotomy in the intensive care unit

OBJECTIVE

To demonstrate that open bedside tracheotomy is an efficient, safe, and cost-effective procedure.

STUDY DESIGN

Retrospective review of more than 200 open bedside tracheotomies performed at UCLA Medical Center, Harbor-UCLA Medical Center, and West Los Angeles VA Medical Center from 1995 to 1998.

METHODS

The only personnel required for the procedure were an attending or senior resident and a junior resident or intern, as well as the respiratory therapist to withdraw the endotracheal tube. No anesthetist or scrub nurse was present for any of the procedures. The procedure took an average of 15 to 25 minutes. Patients were followed for 30 days after surgery to determine the incidence of complications.

RESULTS

The incidence of major complications related to the procedure, including hemorrhage and myocardial infarction, was less than 1%. The incidence of minor complications, including moderate bleeding at the tracheotomy site, was 4%. Overall mortality within 30 days was 8%, but was not related to the tracheotomy for any patients in this series. The charge for the procedure was $233 for the tracheotomy tube supplies and instruments. This cost compares favorably with an average charge of more than $3000 for the procedure in the operating room and about $1000 for a percutaneous tracheotomy kit.

CONCLUSION

Review of our experience demonstrates that open bedside tracheotomies can be performed more efficiently and economically than operating room tracheotomies. The safety of this procedure is comparable to percutaneous tracheotomy but at a decreased cost.

Revised memory and behavior problems checklist in Taiwanese patients with Alzheimer's disease

The Revised Memory and Behavior Problems Checklist (RMBPC) is a 24-item caregiver report that measures observable behavioral and memory problems in dementia patients and their caregivers' reaction to these problems. The purpose of the present study was to evaluate the applicability of the RMBPC for use in Taiwanese patients with Alzheimer's disease (AD). The subjects included 76 AD patients (39 men and 37 women, mean age 72.3) and their caregivers (34 men and 42 women, mean age 53.5) who participated in a comprehensive assessment at the Veterans General Hospital-Taipei. The Chinese version of the Cognitive Abilities Screening Instrument was administered to the patients. Their caregivers rated the RMBPC and the short version of the Geriatric Depression Score (GDS). To assess the test-retest reliability, 30 caregivers rated a second RMBPC 3 days after the first evaluation. The mean score for the frequency rating on the RMBPC was 32.63 (SD = 12.44, range = 5-61) and the mean reaction score was 10.96 (SD = 11.53). The reaction score was significantly correlated with the GDS score (r = .363, p = .001). The Cronbach's alpha coefficients for frequency and reaction scores were .816 and .895 respectively. The test-retest reliabilities of total frequency and reaction scores were significantly correlated; overall correlations were .89 for frequency (p < .001) and .74 for reaction (p < .001). These findings suggest that the RMBPC be recommended as a reliable tool to assess behavioral and memory disturbance in Taiwanese AD patients.

Effect of reaction conditions on preparations of rhenium-188 hydroxyethylidene diphosphonate complexes

Rhenium-186 (Re-186) hydroxyethylidene diphosphonate (HEDP) has been shown to localize in metastatic foci within bone in a manner similar to Tc-99m bone-seeking agents. Usually, in the preparation of diagnostic Tc-99m radiopharmaceuticals, the concentration of Tc is at trace level (10(-8) M). However, large amounts of carrier are included in the preparation of Re-186 radiopharmaceuticals (10(-4) M), which may significantly affect the preparation of Re-HEDP. In this study, Re-188 was used as an Re tracer. The effects of pH and concentrations of Re carrier on the preparation of Re-HEDP were investigated. Re-188-Sn-HEDP was prepared by reconstitution of a kit of lyophilized HEDP mixture, and tin chloride with a radioactive solution of perrhenate in saline. The total concentration of Re present in this work ranged from 10(-8) to 10(-3) M. The results showed that high labeling efficiency was obtained for each preparation. Although the chemical behaviors of the Re-188 HEDP complexes, with and without carrier, were similar, the biodistribution patterns of carrier free Re-188 HEDP in rats were found to differ from the biodistribution patterns of carrier-added Re-188 HEDP.

The caregiving burden scale among Chinese caregivers of Alzheimer patients

From April 1996 to January 1997, a total of 76 Alzheimer's disease (AD) patients and their caregivers were recruited for participation in a comprehensive assessment at the Veterans General Hospital-Taipei, a 2,198-bed tertiary-care teaching hospital in Taipei, Taiwan. The AD patients responded to the Chinese version of the Cognitive Abilities Screening Instrument. Primary caregivers rated the patients using the Symptom Check List-90 (SLC-90) and the Revised Memory and Behavior Problems Checklist and then rated themselves with the caregiving burden scale (CBS), coping strategies scale and the short version of the Geriatric Depression Score (GDS-S). The internal consistency of the CBS, as assessed by Cronbach's alpha, was 0.849. The correlations between the CBS, SCL-90 and GDS-S ranged from 0.435 to 0.698. The CBS scores increased with disease progression and were higher among spouse caregivers than adult children caregivers. Multiple-regression analysis revealed that caregivers with higher CBS scores were more likely to have lower education levels and to use the meaning subscales of coping strategies, and that these caregivers' patients had greater disruptive behavior and were older (R2 = 0.727, p = 0. 001). The current study establishes the reliability and validity of the Chinese version of the CBS for assessment of Chinese caregivers of AD patients.

Botulism: heart rate variation, sympathetic skin responses, and plasma norepinephrine

BACKGROUND

Botulism may involve the autonomic nervous system.

METHODS

We assessed the autonomic function of 6 botulism patients with heart rate variations, sympathetic skin responses, and plasma norepinephrine.

RESULTS

Two weeks after onset, all the patients had absent sympathetic skin response in the palm and sole. Compared with controls, the heart rate variation of botulism patients was significantly decreased at rest (3.1 +/- 1.2% vs. 20.9 +/- 2.0%, p = 0.0018) and during deep breathing (4.3 +/- 2.3% vs. 29.7 +/- 2.6%, p = 0.0018). The botulism patients had significantly lower plasma norepinephrine levels (supine 29.2 +/- 10.1 pg/ml vs. 257.5 +/- 65.8 pg/ml, p = 0.0018; standing 40.3 +/- 13.1 pg/ml vs. 498.5 +/- 85.6 pg/ml, p = 0.0018). The heart rate variation and sympathetic skin response was greatly improved 6 months after onset.

CONCLUSIONS

Heart rate variation, absence of sympathetic skin response, and low plasma norepinephrine are all manifestations of autonomic dysfunction in botulism patients.

Human very-long-chain acyl-CoA synthetase: cloning, topography, and relevance to branched-chain fatty acid metabolism

Very-long-chain acyl-CoA synthetases (VLCS) activate very-long-chain fatty acids (VLCFA) containing 22 or more carbons to their CoA derivatives. We cloned the human ortholog (hVLCS) of the gene encoding the rat liver enzyme (rVLCS). Both hVLCS and rVLCS contain 620 amino acids, are expressed primarily in liver and kidney, and have a potential peroxisome targeting signal 1 (-LKL) at their carboxy termini. When expressed in COS-1 cells, hVLCS activated the VLCFA lignoceric acid (C24:0), a long-chain fatty acid (C16:0), and two branched-chain fatty acids, phytanic acid and pristanic acid. Immunofluorescence and immunoblot studies localized hVLCS to both peroxisomes and endoplasmic reticulum. In peroxisomes of HepG2 cells, hVLCS was topographically oriented facing the matrix and not the cytoplasm. This orientation, coupled with the observation that hVLCS activates branched-chain fatty acids, suggests that hVLCS could play a role in the intraperoxisomal reactivation of pristanic acid produced via alpha-oxidation of phytanic acid.

Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy

BACKGROUND

The impact of banding ligation and injection sclerotherapy on paraesophageal varices and gastric varices has received scarce attention. We conducted a study using endoscopic ultrasound (EUS) to visualize paraesophageal varices and gastric varices in patients who underwent sclerotherapy and banding ligation.

METHODS

Patients with esophageal variceal bleeding whose varices were obliterated by ligation (44 patients) and by sclerotherapy (35 patients) were enrolled. EUS was used to compare the prevalences of paraesophageal varices and gastric varices between the treatment groups. The correlation between paraesophageal varices and esophageal variceal recurrence and recurrent bleeding was assessed.

RESULTS

The prevalence of paraesophageal varices was 86% in the ligation group compared with 51% in the sclerotherapy group (p = 0.002). The prevalence of gastric varices was slightly higher in the ligation group than in the sclerotherapy group (43% vs. 26%, p = 0.18). Esophageal varices recurred in 70% of the ligation group and 43% of the sclerotherapy group (p = 0.04). Patients in both groups with more severe paraesophageal varices had a significantly higher rate of variceal recurrence (p = 0.002 in ligation group and p = 0.001 in sclerotherapy group). Bleeding recurred in 6 patients in the ligation group and 4 patients in the sclerotherapy group. All patients with recurrent bleeding had paraesophageal varices. The rate of recurrent bleeding was significantly higher in patients with paraesophageal varices (p < 0.0001).

CONCLUSIONS

EUS was helpful in the imaging of paraesophageal and gastric varices after sclerotherapy or banding ligation. Paraesophageal varices were more frequently noted in patients undergoing ligation. The presence of paraesophageal varices may predict the recurrence of esophageal varices and recurrent bleeding.

Radiotherapy followed by neck dissection for small head and neck cancers with advanced cervical metastases

Patients with small or occult primary carcinomas of the head and neck with advanced cervical metastases present a difficult problem for the otolaryngologist. A retrospective review was performed of patients who presented to UCLA Medical Center between January 1986 and June 1996 with small or occult primary tumors of the head and neck with advanced cervical metastases. The treatment algorithm consisted of initial radiotherapy to the primary site and the neck, followed in 6 to 8 weeks with endoscopy and biopsy of the primary tumor site. As long as the repeat biopsy of the primary tumor site was negative by frozen section, an immediate neck dissection was performed, even if no residual neck disease was present. Almost 40% of patients with no clinical evidence of neck disease following radiotherapy had evidence of metastatic cancer on histopathologic examination. While some would consider a watchful waiting policy when there is no clinically detectable neck disease following radiotherapy, we believe it is preferable to perform immediate surgery in such patients, in light of the high incidence of microscopic metastatic disease.

Cross-modulation of synaptic plasticity by beta-adrenergic and 5-HT1A receptors in the rat basolateral amygdala

Neurotransmitter receptors are often colocalized in a neuron with other receptors, and activation of one receptor can either amplify or antagonize the response to a colocalized receptor. The aim of this study was to investigate the cross-regulation of synaptic transmission by beta-adrenergic and serotonin 1A (5-HT1A) receptors and to elucidate their underlying mechanisms. Stimulation of presynaptic beta-adrenergic receptors with isoproterenol (Iso) in the basolateral amygdala resulted in a long-lasting increase in synaptic transmission. This effect was mimicked by forskolin, an activator for adenylyl cyclase and a cAMP analog. In addition, the effect of forskolin was blocked by catalytic and regulatory site antagonists for cAMP-dependent protein kinase (PKA), indicating a PKA-mediated mechanism. Application of 5-HT depressed the synaptic transmission and blocked Iso- and forskolin-induced potentiation. The effect of 5-HT was mimicked by the selective 5-HT1A agonist 8-hydroxy-dipropylaminotetralin and was blocked by the selective 5-HT1A antagonist 1-(2-methoxyphenyl)-4[4-(2-phthalimido)butyl]piperazine, indicating its mediation by 5-HT1A receptors. To determine the locus of interaction, Sp-cAMPS, a membrane-permeable activator of PKA, was applied, and the potentiation produced by Sp-cAMPS was completely blocked in slices pretreated with 5-HT. These results suggest that the interaction between the intracellular signaling pathways activated by 5-HT1A and beta-adrenergic receptors occurs at a step downstream from cAMP production.

Ossification of the posterior longitudinal ligament of the spine. A case-control risk factor study

STUDY DESIGN

A case-control study.

OBJECTIVES

To determine the risk factors for ossification of the posterior longitudinal ligament (OPLL) of the spine.

SUMMARY OF BACKGROUND DATA

Previous epidemiologic studies conducted in Japan showed consuming vegetable protein and salt was a risk factor for OPLL. Dietary habits of the Taiwanese and Japanese people are similar. Whether the similar dietary habits play an important role in the high prevalence of OPLL in Taiwan was of interest.

METHODS

A case-control study was conducted in a tertiary teaching hospital. The study included 98 consecutive cervical spine patients with OPLL, with 98 age-matched patients with cervical spondylosis serving as control subjects. Radiologic examinations, clinical interviews, physical examinations, and risk factor questionnaires were administered to all the participants.

RESULTS

Compared with incidence in the control patients, the frequency of the ossification of the anterior longitudinal ligaments was significantly higher in OPLL patients with OPLL (31% vs. 19%; P = 0.049), but there was no difference in incidence of ossification of the ligamentum flavum (13.3% vs. 16.3%; P = 0.546). More OPLL patients preferred a high-salt diet (OPLL/CS, no:somewhat:yes = 23/38:18/25:57/35;, X2 for trend = 6.3; P = 0.001) and pickled foods (OPLL/CS, no:somewhat:yes = 39/56:11/11:48/31; X2 for trend = 6.7; P = 0.0099). Fewer patients with OPLL consumed meat daily (63% vs. 79%; P = 0.018). High-salt diet (odds ratio = 2.62) and daily meat intake (odds ratio = 0.39) showed persistent association with OPLL in a multivariate logistic regression.

CONCLUSIONS

The similar dietary habits, particularly a high-salt and low meat intakes, may partially explain the high prevalence of OPLL in Taiwan and Japan. Modifying dietary habits may help prevent this disease, especially in those high-risk populations.