The validity of the family history screen for assessing family history of mental disorders

There is a need to collect psychiatric family history information quickly and economically (e.g., for genome-wide studies and primary care practice). We sought to evaluate the validity of family history reports using a brief screening instrument, the Family History Screen (FHS). We assessed the validity of parents' reports of seven psychiatric disorders in their adult children probands from the Dunedin Study (n = 959, 52% male), using the proband's diagnosis as the criterion outcome. We also investigated whether there were informant characteristics that enhanced accuracy of reporting or were associated with reporting biases. Using reports from multiple informants, we obtained sensitivities ranging from 31.7% (alcohol dependence) to 60.0% (conduct disorder) and specificities ranging from 76.0% (major depressive episode) to 97.1% (suicide attempt). There was little evidence that any informant characteristics enhanced accuracy of reporting. However, three reporting biases were found: the probability of reporting disorder in the proband was greater for informants with versus without a disorder, for female versus male informants, and for younger versus older informants. We conclude that the FHS is as valid as other family history instruments (e.g., the FH-RDC, FISC), and its brief administration time makes it a cost-effective method for collecting family history data. To avoid biasing results, researchers who aim to compare groups in terms of their family history should ensure that the informants reporting on these groups do not differ in terms of age, sex or personal history of disorder.

How should we construct psychiatric family history scores? A comparison of alternative approaches from the Dunedin Family Health History Study

BACKGROUND

There is increased interest in assessing the family history of psychiatric disorders for both genetic research and public health screening. It is unclear how best to combine family history reports into an overall score. We compare the predictive validity of different family history scores.

METHOD

Probands from the Dunedin Study (n=981, 51% male) had their family history assessed for nine different conditions. We computed four family history scores for each disorder: (1) a simple dichotomous categorization of whether or not probands had any disordered first-degree relatives; (2) the observed number of disordered first-degree relatives; (3) the proportion of first-degree relatives who are disordered; and (4) Reed's score, which expressed the observed number of disordered first-degree relatives in terms of the number expected given the age and sex of each relative. We compared the strength of association between each family history score and probands' disorder outcome.

RESULTS

Each score produced significant family history associations for all disorders. The scores that took account of the number of disordered relatives within families (i.e. the observed, proportion, and Reed's scores) produced significantly stronger associations than the dichotomous score for conduct disorder, alcohol dependence and smoking. Taking account of family size (i.e. using the proportion or Reed's score) produced stronger family history associations depending on the prevalence of the disorder among family members.

CONCLUSIONS

Dichotomous family history scores can be improved upon by considering the number of disordered relatives in a family and the population prevalence of the disorder.

High treatment-related mortality in cardiac amyloid patients undergoing autologous stem cell transplant

Dose-intensive chemotherapy with PBSC support was recently reported to be feasible in cardiac amyloidosis with some patients achieving post-transplant improvement in performance status. At our center, 11 patients with symptomatic primary systemic amyloidosis and predominant cardiac involvement confirmed by biopsy or increased wall thickness on echocardiogram were evaluated for high-dose therapy. The average time from diagnosis to referral was 11 months (4-26 months). Of the 11 patients, two were not candidates for high-dose therapy, based on poor performance status. The remaining nine patients proceeded to PBSC collection. Three patients died during the mobilization period: two of rapid atrial fibrillation, and the third secondary to progressive heart failure. Six patients proceeded to transplantation. However, one died of sudden cardiac arrest the day of melphalan administration, one following hypotension related to stem cell infusion, and one of hypotensive shock the day following stem cell infusion. Three patients recovered and left the hospital, but one died of a cardiorespiratory event at home within 6 weeks of discharge. Both surviving patients demonstrate objective improvement. A decision to use high-dose therapy and stem cell support in cardiac amyloidosis must balance the substantial morbidity of the procedure with the potential benefits. Transplant regimens should avoid cardiotoxic agents such as cyclophosphamide and DMSO and patients should receive anti-arrythmic therapy.

The University of Louisville Medical School's comprehensive programs to increase its percentage of underrepresented-minority students

Since 1981, the University of Louisville (U of L) School of Medicine has developed several programs to increase the number of its underrepresented-minority (URM) matriculants and help them succeed during their medical education. The first such effort, begun in 1981, was the Professional Education Preparation Program for Kentucky high school students from underserved counties. Programs in Louisville's elementary and middle schools were initiated in 1996, and others continue through medical education and residency training. These existing supports for local URM students (most of whom are African Americans) were enhanced in 1996 by the Health Professions Partnership (HPP), a program sponsored by The Robert Wood Johnson Foundation and the Association of American Medical Colleges. With the HPP, the U of L intensified its focus on health careers preparation at the elementary and secondary education levels, and increased exchanges and collaboration between U of L health sciences faculty and teachers and students in the Jefferson Country Public Schools. Several funding sources have been used to maintain and develop the U of L's education pathway programs, including institutional, state, federal, and foundation funds. The authors describe the U of L's programs, focusing on the HPP, and state that as of 1998, the number of URM students enrolled in the U of L School of Medicine had reached almost 10% (up from 2-3% before 1993) and the graduation rate was 90%, (up from 76% before 1993). These increases are the result of many years of developing and implementing a continuum of preparation and retention programs.

Hyperbaric oxygen and thrombolysis in myocardial infarction: the "HOT MI" pilot study

Hyperbaric oxygen treatment (HBO) in combination with thrombolysis has been demonstrated to salvage myocardium in acute myocardial infarction in the animal model. Therefore a randomized pilot trial was undertaken to assess the safety and feasibility of this treatment in human beings. Patients with an acute myocardial infarction (AMI) who received recombinant tissue plasminogen activator (rTPA) were randomized to treatment with HBO combined with rTPA or rTPA alone. Sixty-six patients were included for analysis. Forty-three patients had inferior AMIs (difference not significant) and the remainder had anterior AMIs. The mean creatine phosphokinase level at 12 and 24 hours was reduced in the patients given HBO by approximately 35% (p = 0.03). Time to pain relief and ST segment resolution was shorter in the group given HBO. There were two deaths in the control group and none in those treated with HBO. The ejection fraction on discharge was 52.4% in the group given HBO compared with 47.3% in the control group (difference not significant). Adjunctive treatment with HBO appears to be a feasible and safe treatment for AMI and may result in an attenuated rise in creatine phosphokinase levels and more rapid resolution of pain and ST segment changes.

Time course of changes in P-wave duration during exercise

The exercise-induced increase in P-wave duration reported previously has not been studied on a minute-by-minute basis. We measured the P duration in 47 normal subjects and 43 coronary artery disease (CAD) patients each minute during an exercise test. We found that prolongation of the P wave in those with CAD occurs relatively early and the difference between normal subjects and CAD patients is greater near maximum exercise. The data suggest that an increase in P-wave duration may reflect an increase in the left-ventricular end-diastolic pressure and may occur earlier that ST-segment depression.

Significance of precordial T-wave increase during treadmill stress testing

It appears that a T-wave amplitude increase of > or = 2.5 mm in lead V2 during a treadmill stress test may be specific (95%), even though this finding only occurs occasionally. Therefore, a T-wave amplitude increase during an exercise test may aid in the diagnosis of the few patients who develop this abnormality, especially if there is no ST depression, as has occurred during several recent exercise tests.

ECG myocardial infarct size: a gender-, age-, race-insensitive 12-segment multiple regression model. I: Retrospective learning set of 100 pathoanatomic infarcts and 229 normal control subjects

In this early study of ongoing work with multiple regression modeling for mapping myocardial infarct (MI) into 12 left ventricular (LV) segments, promising results have been presented using electrocardiographic (ECG) QRS variables that are gender, age, and race insensitive (GARI), the GARI-QRS 12-segment multiple regression model. These include Q, R, and S duration, expressed as percentage total QRS duration, and R/Q duration, R/Q amplitude, R/S duration, and R/S amplitude variables. For version I, building 12 regression models using 68 single and 32 multiple MIs, the GARI-QRS variables correlated with pathoanatomic MI in each of 12 segments with r values ranging from .67 to .88. In version II of the model, using all MIs and 229 normal subjects, r = .73-.91. Version II predictions of MI in 12 LV segments for each subject were used to calculate the predicted total percentage LV infarct, which correlated well with that found at autopsy. The r values found were .81 for all single MIs, .73 for multiple MIs, and .80 for all MIs taken together. With refinements of the input ECG variables to include (1) improvement in the GARI-QRS variables, (2) adding a significant number of subjects with hypertrophies and conduction defects with and without MI to an expanded learning set, and (3) applying the enhanced 12-LV-segment regression models to a similar test set, it is to be expected that these regression models can be improved even further in such a way as to be applicable to general clinical populations using routine computerized ECG analysis programs.

Efficacy of pacemaker tachycardia termination algorithms: is electrophysiological testing alone adequate?

Selection of an optimal pacemaker tachycardia reversion algorithm is generally performed utilizing programmed electrical stimulation (PES). Multiple tachycardias are induced and various tachycardia termination protocols are tested for reversion success. However, PES may induce nonclinical tachycardia and result in an inaccurate assessment of subsequent reversion effectiveness for spontaneous tachycardia. To investigate this question, we compared tachycardia reversion protocol success for PES-induced tachycardia versus spontaneously occurring tachycardia in 16 patients with atrially placed Intermedics 262-12 antitachycardia pacemakers. The pacemaker has tachycardia response counters, and the reversion success was calculated from these counters. This was performed by comparing the percent of time 1 degree versus 2 degrees modality use occurred; crossover to the 2 degrees modality implied failure of the 1 degree modality to convert the tachycardia. PES was used to induce multiple episodes of tachycardia and spontaneous episodes of tachycardia were recorded over time by pacemaker counters. The pacemaker 1 degree modality success was then compared for spontaneous and induced arrhythmias.

RESULTS

A total of 53 discrete data comparisons of PES versus spontaneous tachycardia counters were performed in the 16 patients. PES reversion success occurred 85% +/- 22% of the time versus a spontaneous reversion success of 88% +/- 22%. However, the Spearman rank correlation coefficient test demonstrated nonsignficant overall correlation (P < 0.01), and Pearson correlation on an individual patient basis varied widely (r value from < 0.1 to 1.0).

CONCLUSIONS

When utilizing the same termination algorithm, the percentage conversion of tachycardias occurring spontaneously and induced by PES is similar but does not correlate well overall. This suggests that PES may not be a good linear predictor of the long-term success of antitachycardia pacing algorithms.

The effect of chronic atrial overdrive suppression pacing on the incidence of supraventricular tachyarrhythmias

Chronic overdrive suppression pacing has been suggested as an effective adjunctive method for reducing the incidence of cardiac tachyarrhythmias. Documentation of effectiveness during prolonged monitoring is lacking, however. To assess more accurately the long-term utility of this treatment modality for medically refractory supraventricular tachyarrhythmias (SVTs), 10 patients with atrially implanted Intermedics Intertach pacemakers were randomly assigned to either a low or a high bradycardia (back-up) pacing rate. SVT counts were performed during matching follow-up periods both at the initial rate and after rate crossover. The primary antitachycardia modality of this pacemaker (P mod) provides burst pacing to terminate tachycardia episodes, and P mod counters were utilized to quantitate SVT episodes. Tachycardia termination algorithms were programmed to "no restart" and were not changed during the study. The P mod use counter, therefore, reflected the number of discrete episodes of SVTs. Pacemaker implantation diagnoses include atrial flutter, concealed bypass tract, AV nodal reentry, intraatrial reentry, and Wolff-Parkinson-White associated tachycardia. Patient age was 59 +/- 18 yrs. The average pacemaker back-up low rate was 45.7 +/- 4 versus a back-up high rate of 85.1 +/- 2 beats/min. Follow-up was for 57.4 days +/- 33 days at the low rate and 57.3 days +/- 34 days at the high rate (r = 0.99). There was no difference in SVT incidence with a P mod usage of 98.4 +/- 106 at the low rate and 100.8 +/- 94 at the high rate (p = NS). In this blinded, randomized cross-over trial, chronic atrial overdrive suppression pacing did not reduce the overall incidence of SVT episodes during prolonged monitoring.

Analysis of the signal-averaged P-wave duration in patients with percutaneous coronary angioplasty-induced myocardial ischemia

To assess the impact of angioplasty-induced myocardial ischemia on the duration of the surface P wave, patients undergoing elective angioplasty of isolated lesion in the left anterior descending, circumflex or right coronary arteries were monitored with a 3-channel electrocardiographic Holter system. The leads used were modified bipolar chest leads V5, aVF and V2 (CM-V5, CS-aVF and CM-V2). After echocardiographic signal-averaging, the earliest onset and the latest offset of the P wave were identified in all of the above time-aligned signal-averaged leads, and the composite maximal P duration was measured under 10 x magnification. The maximal ST-segment shift during balloon inflation was also measured in all of the above leads at 60 ms after the J point. In the study group comprising 47 patients, the mean signal-averaged P-wave duration was 125.0 +/- 16 ms at baseline versus 130.0 +/- 15 ms during balloon inflation, p less than 0.005. In the left anterior descending coronary artery group (n = 23), the mean signal-averaged P-wave duration was 122.4 +/- 17 ms and 131.3 +/- 16 ms during balloon inflation, p less than 0.005). In the group with a right coronary artery lesion (n = 18), the values were 127.3 +/- 14 ms and 128.4 +/- 13 ms respectively (p = not significant). Significant increases in the P-wave duration were found to occur in groups both with (n = 34) and without (n = 13) ST-segment shift greater than or equal to 1 mm (both p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The significance of lead strength on ST changes during treadmill stress tests

The contribution of relative lead strengths to ST depression during exercise was evaluated in 334 patients who had both a treadmill stress test and an angiogram. Patients were referred for exercise testing for the evaluation of suspected or known coronary artery disease. This was accomplished by comparing the magnitude of ST-segment depression to a constructed ST/R ratio. Using a cutoff of 0.1 for the ST/R ratio, the data were compared to the sensitivity and specificity of the 1 mm criteria for ST depression. There was only a slight increase in sensitivity (59% vs 63%) and specificity (60% vs 78%) for the ST/R ratio in comparison to the standard ST depression. However, when these two criteria were reevaluated for patients with less than or equal to 10.0 mm of R wave amplitude, the 0.1 ST/R ratio had a small decrease in specificity (94% vs 80%) when compared to 1 mm of ST depression and a marked increase in sensitivity with 31% for the standard ST depression and 82% using the ST/R ratio. In those with an R wave greater than 20 mm, 1 mm of ST depression was much more sensitive than the ST/HR ratio (95% vs 59%), but the ratio was more specific than the conventional ST depression (78% vs 59%). It is concluded that ST depression should be corrected for R wave amplitude in patients with R waves less than 10 mm and over 20 mm.

Significance of signal-averaged P-wave changes during exercise in patients with coronary artery disease and correlation with angiographic findings

The maximal P-wave duration in all time-aligned leads, and the maximal P-wave amplitude in leads V5 and V6 were measured on a 12-lead, signal-averaged electrocardiogram during the recovery period of an exercise stress test (EST). The study group consisted of 75 patients with coronary artery disease (CAD) documented by greater than or equal to 50% diameter stenosis in 1 or more arteries and a control group of 47 subjects, 15 of them young volunteers and 32 with no or minimal coronary atherosclerosis and normal left ventricular function. All subjects underwent a symptom limited EST, with use of the Ellestad protocol. Signal-averaged P waves recorded before exercise, and for the first 6 minutes in recovery were measured using a 5x magnifier. The mean P duration before exercise in the control group was 107 +/- 16 ms (+/- 1 standard deviation) and 111 +/- 15 ms at the third minute of recovery, (p less than 0.001). In patients with CAD it was 112 +/- 12 and 129 +/- 19 ms (+/- 1 standard deviation), p less than 0.001, respectively. Differences in P-wave duration were found to be statistically significant (p less than 0.001) throughout recovery in the group with CAD when compared with control and maximal values at the third minute. The increase in P-wave duration (greater than or equal to 20 ms) was used as an additional parameter to exercise-induced ST-segment depression, ST elevation, or anginal pain for the test interpretation. The sensitivity increased from 57 to 75% and the specificity decreased from 85 to 77%.(ABSTRACT TRUNCATED AT 250 WORDS)

Physical determinants of the endocardial P wave

Reliable atrial sensing of intrinsic P wave activity is important to ensure optimal atrial or dual chamber pacemaker function. Various physical factors (e.g., posture, respiration, exercise) may influence P wave characteristics and impair adequate sensing. To investigate this phenomenon, we measured the average of three P wave amplitudes (PWA) and calculated slew rates from telemetered printouts acquired from Pacesetter pacemakers in 32 patients. These measurements were performed in various body positions, with upright exercise and in varying stages of respiration.

RESULTS

the mean supine PWA increased on full inspiration (3.56 +/- 1.3 mV versus 3.25 +/- 1.2 mV during quiet respiration, P less than 0.001), and also increased significantly with full expiration. The mean PWA increased on assuming the erect position (3.25 +/- 1.2 mV increasing to 3.49 +/- 1.3 mV, P less than 0.001); in the upright position, the mean erect PWA during quiet respiration was not significantly influenced by the stage of respiration. The mean upright exercise PWA did not differ significantly from the preexercise erect PWA (3.50 +/- 1.2 with exercise, and 3.47 +/- 1.5 before exercise; P = NS). Calculated slew rates were not different lying versus standing.

CONCLUSIONS

the mean supine PWA increases significantly at the extremes of respiration and on assuming the erect body position; upright exercise results in no appreciable change in the erect PWA. Atrial sensitivity adjustments based on standard supine testing should be adequate for all body positions.