Prolongation of the corrected QT and torsades de pointes cardiac arrhythmia associated with intravenous haloperidol in the medically ill

Consultation psychiatrists are frequently called upon by their medical and surgical colleagues to assist in the management of agitated, delirious patients in the intensive care unit. Intravenous haloperidol has a reputation for safe and effective sedation of these patients and has been found to be free of many of the dangerous anticholinergic and cardiac side effects of the lower-potency neuroleptics. The authors report the cases of three patients who developed torsades de pointes arrhythmia or lengthening of the Q-T interval during treatment with intravenous haloperidol. The cases suggest that the use of intravenous haloperidol should be accompanied by cardiac monitoring and that risk factors for torsades de pointes during haloperidol treatment may include dilated cardiomyopathy and a history of alcohol abuse.

Glomerular hyperfiltration in NIDDM patients without overt proteinuria

OBJECTIVE--To evaluate the frequency and correlates of glomerular hyperfiltration in NIDDM patients without overt proteinuria. RESEARCH DESIGN AND METHODS--A cross-sectional study was conducted. Seventy-one consecutive NIDDM patients attending an outpatient clinic, with Albustix-tested negative urine and a 24-h AER < 200 micrograms/min, were examined for long-term complications of diabetes. We measured their GFR (51Cr-EDTA single-injection method), 24-h AER (RIA), plasma creatinine, HbA1c, total cholesterol, triglycerides, urinary glucose, and urea. RESULTS--GFR above the upper limit of the normal range for age-matched control subjects (137.1 ml.min-1 x 1.73 m2) was present in 15 of 71 (21%) NIDDM patients. Subjects with normal and hyperfiltration did not differ in terms of age, sex distribution, BMI, duration of NIDDM, BP, AER, or frequency of long-term complications. Plasma glucose was significantly higher in subjects with hyperfiltration (mean [range]: 12.8 [4.3-18.7] vs. 8.7 [2.6-17.5] mM). HbA1c failed to reach statistical significance, although it tended to be higher in the group with hyperfiltration (10.4 [6.7-13.9] vs. 9.4 [4.2-16.5]%, P = 0.10). Age (rS -0.37, P = 0.002), FPG (rS 0.45, P < 0.0005), total cholesterol (rS -0.31, P = 0.008), and glycosuria (rS 0.40, P = 0.001) correlated significantly with GFR. In a stepwise multiple regression analysis, FPG, age, and total cholesterol emerged as significant correlates of the dependent variable GFR. CONCLUSIONS--Hyperfiltration occurred in 21% of NIDDM patients without overt proteinuria. FPG and age significant correlates of the GFR in these patients. Cholesterol is significantly (although only modestly) correlated with the GFR.

The psychological impact of infertility: a comparison with patients with other medical conditions

To compare the psychological symptoms of infertile women with patients with other chronic medical conditions, subjects completed the Symptom Checklist-90 (Revised) (SCL-90R), a standardized, validated and widely used psychological questionnaire, prior to enrolling in a group behavioral treatment program. All subjects were female and the totals in each program were as follows: 149 with infertility, 136 with chronic pain, 22 undergoing cardiac rehabilitation, 93 with cancer, 77 with hypertension, and 11 with human immunodeficiency virus (HIV)-positive status. The infertile women had global symptom scores equivalent to the cancer, cardiac rehabilitation and hypertension patients, but lower scores than the chronic pain and HIV-positive patients (p < 0.0001 and p < 0.02 respectively). The anxiety and depression scores of the infertile women were significantly lower than chronic pain patients but not statistically different from the other groups. The results suggest that the psychological symptoms associated with infertility are similar to those associated with other serious medical conditions. Therefore, standard psychosocial interventions for serious medical illness should also be applied in infertility treatment.

The prevalence and predictability of depression in infertile women

OBJECTIVE

To determine the prevalence, severity, and predictability of depression in infertile women compared with a control sample of healthy women.

DESIGN

Subjects were assessed while waiting to see their physician: infertility patients before a visit with an infertility specialist and control subjects before seeing either a gynecologist or internist for a routine gynecological examination. Subjects completed a demographic form and two depression scales.

SETTING

A group infertility practice affiliated with an academic medical center, a hospital-based gynecology practice, and a health maintenance organization internal medicine clinic.

PARTICIPANTS

338 infertile women and 39 healthy women.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale.

RESULTS

The infertile women had significantly higher depression scores and twice the prevalence of depression than the controls; women with a 2- to 3-year history of infertility had significantly higher depression scores compared with women with infertility durations of < 1 year or > 6 years; women with an identified causative factor for their infertility had significantly higher depression scores than women with unexplained or undiagnosed infertility.

CONCLUSIONS

Depressive symptoms are common in infertile women. Psychological interventions aimed at reducing depressive symptoms need to be implemented, especially for women with a definitive diagnosis and for those with durations of 2 to 3 years of infertility.

The noisy elderly patient: prevalence, assessment, and response to the antidepressant doxepin

To measure the prevalence of noisy behavior as a nursing problem, a survey of head nurses was done in a chronic care hospital to identify patients whose vocalizing was frequently disturbing to other patients, staff, or visitors. We found 17 patients among the total of 154. Subsequently, the medical records of 13 surviving subjects were reviewed more exhaustively, and 11 were described as disruptive, usually when they were left alone. Of these "lonely" patients, eight had a previously documented diagnosis of depression. All were demented. Antipsychotic medication had previously been given to all 11 "lonely" patients, but had failed to control their disruptive behavior. Empirically, six patients were treated with doxepin, and in five, all with a history of previous depression, agitation and noisiness diminished. These observations suggest that the prevalence rate of disturbingly noisy behavior among long-term institutionalized elderly patients is about 11% and that the disturbingly noisy patient is often demonstrating depression in conjunction with dementia.

Statistical packages for the Macintosh

These programs represent the entry of the Mac into major statistical computing. We believe that for the physician researcher who is not a statistician, they make the Mac the platform for data analysis. We found that statistics, research design, and data analysis seemed different and much less intimidating to us and our trainees when approached through the Mac. We have reviewed the versions of these programs available at the time of this writing, in May 1992; potential buyers should contact the software publisher for information about more recent upgrades. At this point, our recommendations would be as follows: If you are wedded to SPSS or Minitab, try the Mac versions, and you will be impressed. Otherwise, the choice is between SYSTAT, which has been around long enough to demonstrate its richness and capacity to build on its strengths, and JMP, a brash newcomer, which demonstrates that you can teach an old dog (SAS) new tricks. StatView and SuperANOVA, while endowed with intuitive, easy-to-use interfaces, lack online help--a feature we consider important in a statistics package. We anticipate that the future will lead to simplification of the SYSTAT interface and the addition of more analytic capacities to JMP--and who knows what the next generation of competitors will bring?

The patterning of psychological attributes and distress by "job strain" and social support in a sample of working men

As a test of the "job strain" (job demands-control) model, 297 healthy men aged 30-60 were recruited at eight New York City worksites. The association among job demands and control, social support, and psychological outcomes was tested using both ANCOVA and moderated multiple regression, controlling for demographic variables. The job strain model was supported by various psychological outcome measures, with workers in "active" jobs reporting the highest level of Type A behavior, job involvement, and positive attributional style, workers in "low-strain" jobs reporting the lowest job dissatisfaction and trait anxiety, workers in "passive" jobs reporting the most external locus of control and trait anxiety, and workers in "high-strain" jobs reporting the highest job dissatisfaction. Low social support was associated with greater symptomatology, and a significant three-way interaction (demands x control x support) for job dissatisfaction was observed. While selection of subjects into jobs may partially explain these findings, the results support the hypothesis that working conditions influence psychological attributes and distress.

Mutations in an alternatively spliced exon of h-ras are not associated with loss of heterozygosity on chromosome 11p15.5 in ovarian tumorigenesis

There is evidence that an alternatively spliced exon of the H-ras gene, called idx is associated with down-regulation of H-ras activity. We tested the hypothesis that mutations in this exon play an important role in the development of ovarian carcinomas because loss of heterozygosity at the H-ras locus is frequently observed in these tumors. The idx sequence of 26 different ovarian carcinomas was amplified by PCR and the products were analyzed for possible mutations by single-stranded conformation polymorphism and DNA sequencing. The results showed no idx mutations, even in tumors with a demonstrable loss of one H-ras allele.

Prevalence of raised sodium-lithium countertransport activity in type 1 diabetic patients

The prevalence of raised Na+/Li+ countertransport (CT) activity (greater than 0.41 mmol/liter RBC/hr) was assessed in 185 consecutive insulin-dependent diabetic patients attending an outpatient diabetic clinic. Normoalbuminuria was defined as an overnight albumin excretion rate (AER) of less than 20 micrograms/min (N = 121), microalbuminuria as AER between 20 and 150 micrograms/min (N = 35) and macroalbuminuria as AER greater than or equal to 150 micrograms/min (N = 29). The prevalence of elevated Na+/Li+CT (greater than 0.41 mmol/liter RBC/hr) was 21.5, 42.8 and 51.7% (P = 0.0005), in patients with normo-, micro- and macroalbuminuria, respectively. In the whole group, Na+/Li+CT was significantly related to mean blood pressure (MBP; rs = 0.37, P less than 0.001) and AER (rs = 0.38, P less than 0.001). In a multiple regression analysis the significant correlates of AER, as a continuous variable, or of proteinuria (micro + macroalbuminuria), as a categorical variable, were Na+/Li+CT, MBP, duration of diabetes and glycosylated hemoglobin (HbA1). The frequency of normoalbuminuric patients with high Na+/Li+CT activity fell with duration of diabetes. The risk of proteinuria was significantly greater in patients with raised Na+/Li+CT compared to those with Na+/Li+CT within the normal range (odds ratio 3.8, 95% CI, 1.9 and 7.8). A relative excess of patients with proteinuria (micro + macroalbuminuria) was found in the group with elevated Na+/Li+CT and HbA1 above the median value (8.05%) of the whole population (chi 2 = 9.7, P less than 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Lesion localization in apractic agraphia

Apractic agraphia is an impairment in writing in which the actual orthographic production of letters and words is abnormal despite normal sensorimotor function, visual feedback, and word and letter knowledge. We report one case and review the limited clinicoanatomical literature. Analysis of available cases supports the hypothesis that apractic agraphia is one of several related clinical disorders that are due to the loss of spatially and kinesthetically modulated movements. It is produced by lesions in the superior parietal lobule, usually in the hemisphere dominant for language.

A psychometric analysis of the Mental Adjustment to Cancer scale

This paper describes a psychometric replication study of a British coping scale, the Mental Adjustment to Cancer scale, on 239 USA cancer patients. The internal consistency and construct validity were similar to the original validation study. However, the factor structure was different. Cultural differences between the British and USA patient populations are discussed.

Hereditary nonspherocytic hemolytic anemia due to pyruvate kinase deficiency: a prevalence study in Quebec (Canada)

Fifty-eight cases of hereditary nonspherocytic hemolytic anemia due to pyruvate kinase deficiency were collected from both laboratories that have performed the assay since 1972 and from attending physicians in the province of Quebec. Using the postal addresses of the probands, a prevalence map was constructed according to the administrative regions of the province of Quebec. The prevalence was found to be higher in eastern Quebec (1/81,838) than in western Quebec (1/139,086). Fifty probands were of French Canadian origin whereas the remaining 6 were recent immigrants.

Anger expression, hostility, anxiety, and patterns of cardiac reactivity to stress

The majority of studies investigating the relationships between psychological characteristics and cardiovascular reactivity to stress use a research strategy in which discrete traits are evaluated in isolation. The present study examined the effects of additive and/or interactive relationships among traits on cardiac reactivity to a mental arithmetic task. In addition, impedance cardiographic techniques were employed to examine potential relationships between such psychological traits and a specific measure--pre-ejection period (PEP)--of sympathic influence on the heart. Forty-nine undergraduate men performed a mental arithmetic task while continuous measures of PEP and interbeat interval (IBI) were collected. The subjects then completed questionnaires measuring anger expression, hostility, and trait anxiety. Analyses of variance (ANOVAs) showed a significant main effect for anger-out on PEP change from baseline, but not for IBI. Results also showed that anger-in interacted with anger-out and hostility to affect both PEP and IBI changes significantly. Other results indicated that subjects in the high anger-in/low anger-out and high anger-in/low hostility groups did not show significant PEP change, although they nevertheless showed significant IBI change. These results highlight the importance of the consideration of interactions among traits in predicting cardiac reactivity and of the importance of measuring specific indexes of sympathetic arousal.

Decreased clinic use by chronic pain patients: response to behavioral medicine intervention

The treatment of chronic pain is costly and frustrating for the patient, health care provider, and health care system. This is due, in part, to the complexity of pain symptoms which are influenced by behavior patterns, socioeconomic factors, belief systems, and family dynamics as well as by physiological and mechanical components. Assessment of treatment outcomes is often limited to the patient's subjective, multidimensional, self-reports. Outcome measures based on data about return to work or clinic use can provide more objective assessments of intervention benefits. In this study, a 36% reduction in clinic visits in the first year postintervention was found among the 109 patients who participated in an outpatient behavioral medicine program. Decreased clinic use continued in the first 50 patients followed 2 years postintervention. Decreased use projected to an estimated net savings of $12,000 for the first year of the study posttreatment and $23,000 for the second year.

Pseudoconduction of atrial flutter of a recipient atrium

A nine-year-old girl had an episode of atrial flutter and a nonsustained wide QRS tachycardia during her initial hospitalization after orthotopic heart transplantation. Evaluation of her ECG and telemetric tracing revealed atrial flutter of the recipient atrium and sinus rhythm of the donor atrium. The wide QRS tachycardia was an accelerated ventricular rhythm that was also found on subsequent 24-hour ambulatory ECG monitoring. Timely recognition of recipient atrial arrhythmias prevents inappropriate clinical intervention.

Extracting hydrophobic free energies from experimental data: relationship to protein folding and theoretical models

Solubility and vapor pressure measurements of hydrocarbons in water are generally thought to provide estimates of the strength of the hydrophobic effect in the range 20-30 cal/(mol.A2). Our reassessment of the solubility data on the basis of new developments in solution thermodynamics suggests that the hydrophobic surface free energy for hydrocarbon solutes is 46-47 cal/(mol.A2), although the actual value depends strongly on curvature effects [Nicholls et al. (1991) Proteins (in press); Sharp et al. (1991) Science 252, 106-109]. The arguments to support such a significant increase in the estimate of the hydrophobic effect stem partly from theoretical considerations and partly from the experimental results of De Young and Dill [(1990) J. Phys. Chem. 94, 801-809] on benzene partition between water and alkane solvents. Previous estimates of the hydrophobic effect derive from an analysis of solute partition data, which does not fully account for changes in volume entropy. We show here how the ideal gas equations, combined with experimental molar volumes, can account for such changes. Revised solubility scales for the 20 amino acids, based on cyclohexane to water and octanol to water transfer energies, are derived. The agreement between these scales, particularly the octanol scale, and mutant protein stability measurements from Kellis et al. [(1989) Biochemistry 28, 4914-4922] and Shortle et al. [(1990) Biochemistry 29, 8033-8041] is good. The increased strength of the hydrophobic interaction has implications for the energetics of protein folding, substrate binding, and nucleic acid base stacking and the interpretation of computer simulations.

An overview of chronic fatigue syndrome

BACKGROUND

Psychological and immunologic factors both appear to contribute to chronic fatigue syndrome (CFS). By comparing CFS with other disorders in which fatigue is a prominent symptom, the association between fatigue, psychological vulnerability, depression, and immune function may be further defined. Recent data from psychological, neurologic, and immunologic studies that address these issues are reviewed.

METHOD

Articles and abstracts covering CFS and related topics of fatigue, depression, and postinfectious syndromes were identified through MEDLINE and Index Medicus (1980-1990) and by bibliographic review of pertinent review articles.

RESULTS

The 1988 definition of CFS by the Centers for Disease Control encompasses several conditions in which the major characteristic is severe fatigue associated with constitutional symptoms. Several studies have identified immune dysfunction in CFS patients, but the specificity of these findings remains unclear. Most studies have shown that CFS patients, compared with other patients with chronic medical illness, experience more disabling fatigue. Some investigators have found a higher incidence of concurrent and past psychiatric illness in CFS patients compared with other medical patients, thereby suggesting an underlying psychopathology in CFS. However, other studies have not found a higher than expected incidence of past depression in CFS patients and have further shown that many CFS patients have no identifiable psychopathology.

CONCLUSION

CFS appears to be a heterogenous entity. Although there may be a high coincidence of major depression in CFS, a substantial proportion of patients lack any identifiable DSM-III-R psychiatric disorder yet still manifest the syndrome, thereby suggesting it has an autonomous entity. Despite the evolving nature of our current understanding of CFS, a rational diagnostic and therapeutic approach to CFS is possible.